| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(a) | There are not screens in the windows of Individual #1's bedroom. The windows are able to be opened. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Screens were placed in windows on 2/15/2021. The program specialist arranged for screens to be installed. The program specialist will check monthly to ensure that screens are still installed and will report to the program director this information. Training on regulation 6400.72(a) was provided to staff. Supporting documentation attached. |
02/15/2021
| Implemented |
| 6400.141(c)(3) | Individual #1 most recently received a Tetanus immunization on 9/19/2010. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Individual #1 did not receive the Tetanus immunization due to medical insurance deciding not to cover the cost because of being over age 70. Individual #1 could not afford the cost at that time. Individual #1 is now scheduled for the Tetanus immunization on 3/10/21 due to receiving the first COVID vaccine on 2/2/2021 and the second vaccine to be received on 2/23/2021. According to Individual #1¿s PCP, the Tetanus immunization cannot be given for at least 2 weeks afte the 2nd COVID vaccine. The agency will use the ¿Special Account¿ to help defray this cost for Individual #1 that cannot afford mandated medical treatment as well as all other individuals who cannot afford services not covered by insurance. The program specialist will notify the program director if any individual cannot afford medical costs so that the agency will remain in compliance. Supporting documentation attached. |
03/10/2021
| Implemented |
| 6400.34(a) | Individual #1 was informed and explained individual rights on 1/2/2021. The rights document did not include the following rights: 6400.32d, to be treated with dignity and respect; 6400.32e, the right to make choices and accept risks; 6400.32f to refuse to participate in activities and services; 6400.32g, to control his own schedule and activities; 6400.32h, to control his own schedule and activities; 6400.32l, to receive scheduled and unscheduled visitors and to communicate and meet privately with whom the Individual chooses, at any time; 6400.32q, to furnish and decorate the Individual's bedroom and the common areas of the home; 6400.32r, to lock the Individual's bedroom door; 6400.32s, to have a key, access card, key code or other entry mechanism to lock and unlock an entrance door of the home; 6400.32t, to access food at any time; 6400.32u, to make health care decisions; 6400.32v, right may only be modified accordance with 6400.185. | 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. | Individual #1 was informed of the revised rights on 2/10/2021 by the staff and program specialist. These individual rights were immediately corrected by the program director and were reviewed with the staff and program specialist. These rights will be reviewed with the individual with staff assistance. After completion they will be reviewed by the program specialist and program director for signature to ensure that the correct set of rights are received by the individual and that they were completed within the annual timeframe. Staff were trained on regulation 6400.34(a). Supporting documentation attached. |
02/10/2021
| Implemented |
| 6400.165(e) | Tramadol 50mg prescribed to Individual #1 was discontinued by the healthcare professional in September 2020; however, the medication continued to be included on Individual #1's February 2021 Medication Administration Record. | Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received. | Changes in medication will only be made in writing and will be updated immediately on the individual¿s medication record as soon as a written notice of change is received. Staff at the home were retrained in documentation by the medication administration trainer and reviewed by the program specialist and the program director. The agency registered nurse will also review the MAR on a monthly basis. Supporting Documentation attached. |
02/16/2021
| Implemented |