| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | Individual # 2's bedroom dresser is missing the top drawer and the bottom two drawers. Program Specialist stated that Individual # 2 removes these drawers as personal preference. This information is reportedly not contained in Individual # 2's ISP. TA provided to include this preference in Individual # 2's ISP. | Floors, walls, ceilings and other surfaces shall be in good repair. | Individual #2 prefers that these drawers be removed from his dresser as this has been consistent behavior. An email has been sent by the Program Director to the Supports Coordinator stating the concern and requesting that this be documented in his ISP. See Attachment #!12 |
10/23/2019
| Implemented |
| 6400.74 | The wooden step from the deck to the yard does not have a non-skid surface. The step is painted. | Interior stairs and outside steps shall have a nonskid surface.
| Non-skid tape was placed on the deck step and the deck as a person would step up on to. See Attachment #11. |
10/25/2019
| Implemented |
| 6400.80(a) | Between the deck and the door to the garage is a hole where the deck does not extend to the threshold of the garage door creating a hazard. The distance between the deck and the ground is approximately 2 feet. The distance between the deck and the threshold of the door is approximately 2 ½ feet. This is a safety hazard as individuals might step into the hole. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | A contractor was contacted by our agencies COO on Tuesday 10/29/19 about this concern. The contractor visited the home on 10/30/19 to examine the work that needed to be done. His plan is to fill the gap with treated lumber so that the deck is flush with the garage door. Until the correction is made, that entrance to the garage will be blocked. See Attachment #10 |
11/15/2019
| Implemented |
| 6400.141(c)(4) | Individual # 1 did not receive a hearing screening on the 03/13/19 physical exam. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | For each male individual there will be a chart in place to ensure all hearing examinations are completed annually as well an individualized chart to be placed in the emergency medical file of each male individual by the Program Supervisor. This is to ensure staff are aware of when the examination should be completed. Charts will be checked on the first of each month by the Program Director/Supervisor to ensure the examination is not missed. Staff will contact supervisory staff after the examination is completed. See Attachment #9. |
11/04/2019
| Implemented |
| 6400.141(c)(9) | Individual # 1 did not receive a Prostate Exam in the calendar year 2018. | The physical examination shall include: A prostate examination for men 40 years of age or older. | For each male individual there will be a chart in place to ensure all prostate examinations are completed annually as well an individualized chart to be placed in the emergency medical file of each male individual by the Program Supervisor. This is to ensure staff are aware of when the examination should be completed. Charts will be checked on the first of each month by the Program Director/Supervisor to ensure the examination is not missed. Staff will contact supervisory staff after the examination is completed. See Attachment #8. 03/05/20, This will be the first due date for a prostate exam for any CRS individual. |
03/05/2020
| Implemented |
| 6400.166(b) | Individual # 1's 7:30pm medication administration for Fluticasone Propionate 50 mcg was not initialed on the MAR on 05/28 & 29/19. Additionally, Individual # 1's 11:30am and 3:30 pm dosages of both Erthromycin 5 mg ointment and Polymyxin B drops were not initialed as given on 05/20/19.
Individual #1's 7:30 am dosage of Listerine Total Care was not initialed on the MAR on 05/19/19.
Individual # 1's 7:30 Am dosage of Amlopdipine 5mg, was not initialed on the MAR on 04/20/19.
Individual #1's 7:30 pm dosage of Fluticasone Prop 50 MCG nasal spray was not initialed as given on 04/30/19. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Medications administration training will be completed for the staff who worked the months of these errors by a Medications Administration Trainer. See Attachment #7a. Monthly reviews will be completed by two supervisors, a medication trainer and another supervisor (not necessarily another medication trainer). Once the errors are documented the review will be returned to the staff to point out the errors. They will subsequently be trained, by a medication trainer, in an attempt to prevent future errors. The monthly review log that denotes the errors of the staff will be initialed by staff and the medication trainer providing the training along with the date that the training took place. See Attachment #7b. A completed training log will be forwarded to licensing as well as a completed monthly review log. |
11/12/2019
| Implemented |