| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(4) | No hearing screening was provided for Individual #1. Individual #1 had a vision screening in March 2023 and not again until 5/28/24, outside of the annual timeframe. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | The Program Supervisor will call to schedule an audiological appointment for Individual #1 by 11/27/2024. (See attached documents indicating compliance with annual vision and hearing screening requirements for another individual.) |
12/20/2024
| Implemented |
| 6400.144 | Individual #1 was prescribed Hydroxyzine 25 mg 1 tab 4 times a day as needed for itching on 7/16/24. The medication prescription was not filled until 7/30/24. Individual #1 needs assistance with showering. From January 2024 to October 2024 there were 188 days that no shower or bath was documented. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| The Director of IDD Services will meet with the Program Supervisor by 11/27/2024 to train them on the requirements related to timely obtaining, entering on the eMar, and administration of medications upon order by the prescribing physician(s). Current staff working at the home were trained by the Program Specialist on 11/19/2024 on Individual #1's ISP, Outcomes and Individual Action Steps and documentation, Health and Medical Needs, Safety and Supervision, SEEN/Behavior Support Plan, Protocols, Communication Strategies, and Fall Risk Assessment. (See Team Meeting Note dated 11/19/2024) Employees not routinely assigned to home will be trained in the above by the Program Supervisor and/or Program Specialist prior to working with individuals in the home. |
12/20/2024
| Implemented |
| 6400.212(a) | On 2/7/24, Individual #1's daily service notes talk about an individual by the name of "Chris." | A separate record shall be kept for each individual.
| The Director of IDD Services will meet with the Program Supervisor and Program Specialist by 11/27/2024 to train them on the requirements of this regulation to maintain a separate record for each individual and reiterate the expectations for the review of all note types and outcome documentation in the individual's record. The Program Supervisor and Program Specialist will communicate/train employees working in the home of this regulation by 11/27/2024. |
12/20/2024
| Implemented |
| 6400.18(b)(2) | None of the medication errors documented in 167a1 were reported to EIM. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person:
A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner. | Medication errors entered into EIM on 11/23/2024 by Director of IDD Services. Incident report numbers 9523924, 9523925, 9523926. |
12/20/2024
| Implemented |
| 6400.52(c)(6) | Staff #1-Staff #18 worked in the home with Individual #1 from January 2024 to the present. Staff #1, #2, and #7-18 were not trained on Individual #1's Feeding Protocol. Staff #3, #4, and #7-18 were not trained on Individual #1's ISP, Assessment, or Behavior Support Plan. Staff #5 did not receive training on Individual #1's Assessment or Behavior Support Plan. A Fall Risk Screening Tool was completed on 10/19/24. No staff were provided training on the recommendations. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | Current staff working at the home were trained by the Program Specialist on 11/19/2024 on Individual #1's ISP, Outcomes and Individual Action Steps and documentation, Health and Medical Needs, Safety and Supervision, SEEN/Behavior Support Plan, Protocols, Communication Strategies and Fall Risk Assessment. (See Team Meeting Note dated 11/19/2024) Employees currently not working at the home but who may be assigned to the home in the future will be trained in the above by the Program Supervisor and/or Program Specialist prior to working with individuals in the home. (See Attached Team Meeting Form dated 11/19/2024). |
12/20/2024
| Implemented |
| 6400.165(b) | Individual #1's Mag 64 was discontinued. No order was provided documenting the discontinuance. | A prescription order shall be kept current. | The Program Director will meet with the Program Supervisor by 11/27/2024 and train them on the requirements of this regulation. The Program Supervisor will call Individual #1s prescribing physician to obtain a copy of the order of the discontinuance of the Mag 64. |
12/20/2024
| Implemented |
| 6400.167(a)(1) | Individual #1 is prescribed Mag 64 to be administered daily. Individual #1 did not receive their Mag 64 on 3/22/24. Individual #1 was prescribed Famotidine on 4/26/24. They were not administered this medication until 7/16/24. Individual #1 is prescribed Vitamin D. They did not receive their dose on 10/13/24. | Medication errors include the following: Failure to administer a medication. | The Program Director will meet with the Program Supervisor by 11/27/2024 and train them on the requirements of this regulation, the expectation and procedures for review of the eMARs, follow-up required with employees and discuss the appropriate employee corrective action(s). |
12/20/2024
| Implemented |