| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The front and inside surfaces of the kitchen cabinets were visibly soiled with spills and a build up of what appeared to be fingerprints and grime. The windowsill of the upstairs extra bedroom was filled with a layer of chipped paint and what appeared to be dirt and debris from outside. Clean and sanitary conditions shall be maintained in the home. | Clean and sanitary conditions shall be maintained in the home. | Program Specialist of the home instructed staff to immediately clean the inside and outside of all kitchen cabinets. IHRS discussed possible replacement of kitchen cabinets as they are also worn from age. Additionally, Program Specialist of the home instructed staff to clean all windows and window sills to ensure debris is removed. Multiple unannounced site checks made by Program Specialist to ensure that tasks were completed and maintained. |
| Implemented |
| 6400.66 | The lighting in the downstairs bathroom was insufficient with only one of the four bulbs available above the sink producing light. The same bulb was flickering and not producing a steady glow. The lighting in the upstairs bathroom was insufficient with one lightbulb above the sink. The remaining bulbs were out in that fixture as well as the fixture in the shower and above the commode. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| IHRS contacted company electrician immediately to address lighting above sink, above commode and shower. Electrician has corrected issues. |
10/31/2022
| Implemented |
| 6400.112(d) | Fire drills conducted on 8/31/22, 6/8/22, 5/26/22, 10/13/21 and 9/27/21 all had evacuation times exceeding the allowed 2 1/2 minutes. There was no documentation from a fire safety expert granting additional evacuation time in place at the time of inspection. | 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 employe 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. | Program Manager will contact fire safety expert to evaluate if an extended evacuation time is necessary and meets safety needs. Program Specialist will also contact a fire safety expert to provide training to all individuals in the home regarding fire safety. |
10/31/2022
| Implemented |
| 6400.141(a) | There was no current yearly physical exam on file for Individual #2. Last physical documented occurred on 5/7/21. Annual physical examination is required. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual's physical was completed on 4/28/22. I believe I sent this to the inspector after the file review. |
04/28/2022
| Implemented |
| 6400.141(c)(9) | Documentation of a prostate exam or PSA level was not on file for Individual #5 who is 52 years of age. A prostate examination for men 40 years of age or older is required. | The physical examination shall include: A prostate examination for men 40 years of age or older. | Prostate Exam will be requested immediately. PCP initially deferred the prostate exam but IHRS will attempt to educate PCP on importance of exam and regulatory requirements. |
10/31/2022
| Implemented |
| 6400.142(a) | Individual #5 had a dental exam and cleaning on 9/3/21. There is no documentation to support that an annual exam had been completed as of 9/21/22. Annual examination and cleaning is required. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Program Manager scheduled dental exam after licensing review. Dental exam will be completed. |
10/31/2022
| Implemented |
| 6400.144 | Dental exam completed for Individual #2 on 11/18/21 recommended a six month visit to be conducted in 5/2022. A follow up dental exam was not conducted until 7/5/22. Individual #5 was last seen for a dental exam on 9/3/21 and was recommended to return on 3/14/22. There is no documentation to support that the 3/14/22 appointment had been conducted as recommended. | 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.
| CEO will give individual feedback and training to Program Manager. Program Manager will be required to submit due dates for client appointments and follow up to Nursing department for additional oversight. Compliance Department will be asked to review client file on a monthly basis to ensure follow up for the next six months. Training on documentation as to why an appointment may have been missed will be provided to Program Manager. |
10/31/2022
| Implemented |
| 6400.34(a) | Review completed on 6/4/22 for Individual #2 and #5 was not a complete review of all rights as outlined in 6400.32. Rights missing are as follows: a, b, d, e, f, g, h, i, j, p, q, r, s, t, u and v. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | IHRS had revamped all their individual rights forms. However, it is believed that an old form was used to complete the individual rights when clients had yearly review. IHRS will review updated form with both client that covers all rights as listed in 6400.32. IHRS Program Specialists will be retrained in Individual Rights so that they may identify any discrepancies moving forward. |
10/31/2022
| Implemented |
| 6400.165(g) | Three-month medication reviews for Individual #2 conducted on 8/16/22 and 5/13/22 did not contain the reason for prescribing or the dose of the medication reviewed. The medication review conducted on 7/19/22 for Individual #2 did not contain the reason for prescribing the medication. The three-month medication reviews conducted on 9/13/22 and 8/11/22 for Individual #5 did not contain the dose of the mediation or the reason for prescribing the medication. documentation of the reason for prescribing the medication, the need to continue the medication and the necessary dosage is required to satisfy regulation. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Three Month Med Review appointments were completed on wrong agency form. IHRS Three Month Med Review form addresses all necessary items required by regulation. Program Manager has and continues to attempt to have proper form filled out by psychiatrist. Program Manager will monitor all three month med review forms moving forward. |
10/31/2022
| Implemented |
| 6400.194(b) | The restrictive procedure plan in place for Individual #2 was authored by Staff #6. Staff #6 signed as a member of the human rights team approving use of the plan. The plan team did not contain any other professionals with a recognized degree, certification or license relating to behavioral support. | The human rights team shall include a professional who has a recognized degree, certification or license relating to behavioral support, who did not develop the behavior support component of the individual plan. | The plan itself was signed by the Behavior Specialist. The Human Rights Committee does consist of individuals with Master's degrees who vote on the use of the plan. IHRS will examine if the Master's Degrees of the team members meet requirements outlined in the regulation. |
12/09/2022
| Implemented |