| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(e)(3) | Individual #1 made a purchase on 08/28/2013 for $22.98 and there wasn't a receipt | (3) Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person.
| Duplicate copies of receipts over $15 will be maintained. Currently, receipts are copied, sent to Advocacy Alliance, Rep. payee, and kept on file at the home and the office. One additional copy will be made. |
11/20/2013
| Implemented |
| 6400.68(c) | Two Coliform Water Tests were missed between October of 2012 and July of 2013 | (c) A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources' certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept.
| Coliform water tests will be completed every 3 months and results will be kept on file at the home and office. Testing dates will be recorded on both the PS and Home supervisor calendar to ensure prompt testing. |
11/20/2013
| Implemented |
| 6400.112(d) | On September 5, 2013 the evacuation time for a fire drill was 2 minutes and 45 seconds. | (d) Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employee of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home.
| On Sept. 5, 2013 @ 6AM a test overnight drill was completed because JD was experiencing an overall decline in mobility. On Sept.6, 2013, we provided additional staffing during sleep hours to ensure JD's safety. We also requested and received Additional Individualized Staffing. Since the additional overnight staffing has been in place, JD has evacuated within the 2.5 minute time frams. |
09/06/2013
| Implemented |
| 6400.141(c)(6) | Individual #1 did not have a Tuberculin skin test completed within the two year time frame. | (6) Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted.
| A desensitization plan was put into effect following the individual's refusal for the Mantoux test. Individual had a Mantoux test on 6/26/2013. The individual will have a TB skin test within a two year time frame. |
11/20/2013
| Implemented |
| 6400.144 | Artificial Tears was prescribed for Individual #2-------The original order stated to administer the eye drops four times per day, the medication label and the medication administration record stated to administer the eye drops every hour from 8am to 8pm and the CLA staff said that they administer this medication only during awake hours-----------there are too many discrepancies regarding the correct administration of this medication. | 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.
| Prescribing physician contacted and clarified administration of artificial tears; one drop, left eye, each hour for awake hours. |
11/20/2013
| Implemented |