| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.144 | Health services including dental follow up appointments are not planned for or arranged. Individual #1 had an annual dental exam on 6/28/23 and was referred to an oral surgeon for follow up for cavities. Individual #1 expressed wanting to see a specific dentist. There was no documentation of attempts to schedule with this dentist. Individual #1 had a dental appointment on 9/5/23 with a second dentist who also referred the individual to an oral surgeon. There was no documentation that an appointment was scheduled with an oral surgeon. | 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.
| Individual is scheduled to see an Oral Surgeon who specializes in sedation and seizure disorder sedation on January 28, 2025. She is also on a cancellation list to receive a call should another appointment open up sooner. Program Director will retrain Program Manager and Program Coordinator on regulation 6400.144 by February 28, 2024. |
02/28/2024
| Implemented |
| 6400.46(b) | Staff #1 did not complete fire safety annually. Staff #1 was hired on 1/31/22 and completed fire safety training as part of new staff orientation. Staff #1 did not complete fire safety again until 10/5/23. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | The Program Director will retrain all employees in this home, to include, the Program Manager and Program Coordinator, on regulation 6400.46(b) by February 28, 2024. A procedure has been implemented to remove any employee from the work schedule if they fall out of compliance until they receive the necessary training to be in compliance. Program Manager and Program Coordinator will receive training by February 28, 2024 on utilizing the agency In-service Tracking Sheet as a tool to maintain staff training compliance. |
02/28/2024
| Implemented |
| 6400.166(b) | Individual #1 is prescribed Hydroxy 25mg at 2PM. The initials of the person administering the medication were not documented on the medication administration record (MAR) on1/5/24 at 2PM. Individual #1 is prescribed Ketoconazole SHA at 9PM. The initials of the person administering the medication were not documented on the MAR on 1/3/24 at 9PM. Individual #1 is prescribed Oxcarbazepin 300mg 1.5 tablets at 9PM. The initials of the person administering the medication were not documented on the MAR on 1/10/24 at 9PM.
Individual #1 has standing orders for PRN medications Acetaminophen, Ibuprofen, Pink bismuth, triple antibiotic ointment, Tussin CF, Sore Throat Spray and Children's Dimetapp. These medications are not documented on the medication administration record. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Staff will be retrained by the Staff Development Coordinator by February 28, 2024 on Medication Administration Documentation. The Program Director will retrain all employees in this home, to include, the Program Manager and Program Coordinator, on regulation 6400.166(b) by February 28, 2024. Standing Orders added to MAR starting February 1, 2024 |
02/28/2024
| Implemented |