| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.77(b) | At the time of the inspection, the first aid kit in the home did not have scissors available. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | The scissors in the First Aid kit were replaced during the inspection on 06/16/2023. (picture attached 1st aid kit and scissors). |
08/20/2023
| Implemented |
| 6400.111(f) | The home was unable to produce the date the fire extinguishers were inspected and approved in 2022. The home produced an invoice that was created on 5/7/2022 stating payment is required for the inspection of fire extinguishers, indicating the inspection happened sometime prior to 5/7/2022. The home did not have the fire extinguishers inspected and approved again until 5/23/23, more than 365 days after an inspection prior to 5/7/2022. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | The agency scheduled next year's appointments for all sites for the fire extinguisher inspections. The appointment is scheduled for May 13, 2024 at 8:00 am. The company will also give a courtesy call 30 days prior as a reminder or if a rescheduled date will be needed. (Email attachment) |
08/20/2023
| Implemented |
| 6400.141(c)(14) | REPEAT from 7/5/2022 annual inspection: Individual #1's current, 05/25/23 annual physical examination record states that "information pertinent to diagnosis and treatment in case of emergency' is "n/a" (not applicable); this information is applicable, Individual #1 has medical conditions that would be pertinent in an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Individual #1's annual physical was corrected on 06/16/2023 and faxed to the agency (see attachment annual Physical) to reflect information pertinent to diagnosis and treatment in case of emergency. |
08/20/2023
| Implemented |
| 6400.143(a) | There is a note in the Individual #1's record that they refused to attend a scheduled, 11/28/22 follow-up medical care appointment. There is no record of a refusal plan being developed or attempts at retraining in the record. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | Individual #1's Behavioral Specialist implemented a refusal plan per the Behavioral Support Plan on 6/26/23 (see attachment BSP). |
08/20/2023
| Implemented |
| 6400.181(e)(10) | Individual #1's current, 10/31/22 assessment did not include the individual's lifetime medical history at the time the assessment was created and sent to team members. The lifetime medical history attached to their 10/31/22 assessment wasn't created until May 2023. | The assessment must include the following information: A lifetime medical history. | The assessment for individual #1 didn't have an updated lifetime medical history to reflect the lifetime medical history.
The Healthcare Director in collaboration with the Residential Director will ensure the agency DSPs, Nurses, Lead Staff, all Administrators are also trained on timeliness of updating lifetime medical histories.
This will ensure that all documentation for Lifetime Medical Histories will be completed annually and/or as needed per medical history.
The Healthcare Department Director and Associate Residential Services Director will collaborate and train on documents and quality assurance processes. |
08/20/2023
| Implemented |
| 6400.186 | Individual #1's current Individual Support Plan (ISP), last updated 03/16/23, states that individual #1 is not financially independent enough to manage cash. Staff have given the individual cash throughout the past year to carry, with receipts that state "According to the latest ISP/Assessment for the above-named consumer, he or she is able to handle (Amount of Money) of personal money". Per the current ISP, this information is not accurate. | The home shall implement the individual plan, including revisions. | An assessment of financial management will be conducted by the Program Specialist or Designee on individual #1 to determine the appropriate amount of personal money that can be handled for personal use by 8/202/23.
Once the amount is identified from the team, all training will be scheduled and completed by the Program Specialist or Designee to ensure compliance is maintained in this area.
The Direct Support Professionals Lead Staff, and Administrators will be retrained on the tracking, monitoring, and frequency regarding money management.
The Program Specialist or Designee will update information and submit to the Support Coordinator relevant to this individuals ISP and Assessment once all training sessions and follow ups with team are finalized. |
08/20/2023
| Implemented |