| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.113(a) | Annual fire safety training was not found in record for individual 1. Last fire safety training in record was 1/9/20 | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | Based on the licensing review of November 8-9, 2021, the CLA Director, on 11/10/21, retrained the Program Specialists responsible for the completion of the fire safety trainings, as well as the Assistant Directors, about the importance of ensuring that the Fire Safety Training is completed within regulatory timeframes. |
11/19/2021
| Implemented |
| 6400.141(c)(8) | Annual mammogram for individual 1 was not completed within the annual timeframe, it was completed 7/29/20, and then 10/12/21. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | Based on the licensing review of November 8-9, 2021, the CLA Director, on 11/11/21, retrained the Nurses and Healthcare Assistants about the importance of ensuring that consumer medical appointments are scheduled and completed per regulatory guidelines. Additionally, Nurses and Healthcare Assistants will seek appointments and when not available, documentation from the medical provider about any delays, following up with them every 15 days. The Nurse is responsible to ensure all medical appointments/documentation are regulatory compliant. |
11/20/2021
| Implemented |
| 6400.144 | Pro air heapa inhaler prescribed to individual 1 to be taken as needed was not in the medication bin at the time of inspection. | 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.
| Based on the licensing review of November 8-9, 2021, the CLA Director, on 11/10/21, retrained the Site Supervisors responsible for the sites, as well as the Assistant Directors about the importance ensuring that all current medication reflected on the MAR, including PRN¿s, are on site and refilled as necessary before the last dosage. It is the responsibility of the Site Supervisor to ensure all current medication is on site. The residential staff at this site were also given verbal feedback about the importance of complying with 6400 regulations on the day regarding assuring that all medication, including PRN medications, should be available and on site (11.08.21). |
11/09/2021
| Implemented |
| 6400.181(e)(11) | Individual 1 is on psychotropic medications; however, no quarterly psych evaluations were found in the record. | The assessment must include the following information: Psychological evaluations, if applicable. | Based on the licensing review of November 8-9, 2021, the CLA Director, on 11/11/21, retrained the Nurses and Healthcare Assistants about the importance of ensuring that consumer psychological appointments are scheduled and completed per regulatory guidelines. Additionally, Nurses and Healthcare Assistants will seek appointments and when not available, documentation from the medical provider about any delays, following up with them every 15 days. The Nurse is responsible to ensure all psychological appointments/documentation are regulatory compliant. |
10/19/2021
| Implemented |
| 6400.181(e)(14) | The assessment lists individual 1 as having the ability to swim, and in the same document it lists the individual's inability to swim. This discrepancy makes it difficult to determine the individuals actual ability. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | Based on the licensing review of November 8-9, 2021, the CLA Director, on 11/10/21, retrained the Program Specialists responsible for the completion of the assessment, about the importance of ensuring that the assessment is clear and consistent about the individual¿s progress and capabilities, with no discrepancies and completed within regulatory timeframes. |
12/09/2021
| Implemented |