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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | At the time of inspection on 10/5/23, there was a can of artificial snow in a cabinet in the dining room. This was labeled keep out of reach of children and had a medical emergency info phone # listed. Per individual #3's ISP, poisonous substances must be locked in the home. | Poisonous materials shall be kept locked or made inaccessible to individuals. | 10/13/2023 Program specialists, working managers, and nurses were trained on their responsibilities including Poisonous materials shall be kept locked or made inaccessible to individuals.
10/13/2023 A training record was signed indicating their attendance, understanding and knowledge of future procedures to ensure poisonous materials are kept locked. All program specialists, working managers and nurses will continue to review and ensure poisonous materials are kept locked or made inaccessible to individuals. (Attachment #1)
10/13/2023 The SFI Safety Inspection Checklist was updated to include a review that all poisons are stored properly and locked if needed. This includes anything that has Poison Control info or "Keep out of reach of children" on it. (Attachment #2) |
10/17/2023
| Implemented |
| 6400.110(f) | At the time of the inspection on 10/5/23, individual #2's, bed alarm/shaker was not operative. | If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. | 10/5/2023- A maintenance request was completed to include the purchase and installation of a bed alarm for Individual #2's bed. (Attachment #3)
10/6/2023- A new SafeAwake Smoke Alarm Aid with Bed Shaker was purchased online from Hear it Better for Individual #2's bed. (Attachment #4)
10/6/2023 The Health Safety Inspection form that is completely monthly with the fire drill was updated to include checking equipment for hearing impaired, if applicable, to ensure it was working during the drill. (Attachment #5)
10/13/2023 Program specialists and working managers were trained on their responsibilities including: if one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire.
10/13/2023 A training record was signed indicating their attendance, understanding, and knowledge of future procedures to ensure smoke detectors, fire alarms and equipment is in working order for individuals or staff persons who are not able to hear the smoke detector or fire alarm system. All program specialists and working managers will continue to verify that smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire.
(Attachment #1)
10/18/23 A new SafeAwake Smoke Alarm Aid with Bed Shaker had to be ordered when it was determined the original order on 10/6/23 was canceled by the company (Hear it Better) without notification to Strawberry Fields. (Attachment #6) |
11/12/2023
| Implemented |
| 6400.144 | (Repeat from 10/2022 inspection) - Also, on the date of the home inspection, 10/5/23, the PRN medication MUCINEX COLD LIQ FLU & SORE was not available in the home for individual #1. | 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.
| 10/6/2023-The Monthly Supervisory Documentation form was updated to include a review and verification that all prescription and PRN medications are present at the home and documented correctly on the MAR. (Attachment #7)
10/9/2023 Mucinex was purchased for Individual #1 and put in their medication area. (Attachment #8)
10/13/2023 Program specialists, working managers and nurses were trained on their responsibilities including 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.
10/13/2023 A training record was signed indicating their attendance, understanding and knowledge regarding all medications being present at the home. All program specialists, working managers and nurses will continue to review all health services such as medical, nursing, pharmaceutical, dental, dietary and psychological that are planned or prescribed to ensure they are arranged and provided. (Attachment #1)
10/13/2023 Program specialists and working managers were trained on correctly utilizing the Monthly Supervisory documentation form, which includes a review of medications and MARs. Prescription and PRN meds are present at the home and documented correctly on the MAR. (Attachment #1) |
10/19/2023
| Implemented |
| 6400.166(a)(11) | On the MAR reviewed at the home inspection on 10/5/23 for individual #1, the following medications did not have diagnoses listed on the MAR: Topiramate 50mg, Trintellix 5mg, and Vit D3. All of these medication boxes state diagnosis as See ISP. This is also the case for PRN medications Banophen and Robitussin. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | 10/6/2023 The Monthly Supervisory Documentation form was updated to include verification each medication has a diagnosis or purpose listed on the medication record including pro re nata. (Attachment #7)
10/9/23 Individual #1's MAR was updated to include the diagnosis/purpose of medication for each medication. (Attachment #9)
10/13/2023 Program specialists, working managers, and nurses were trained on their responsibilities including: a medication record shall be kept, including the following for each individual with whom a prescription medication is administered: diagnosis or purpose for the medication, including pro re nata.
10/13/2023 A training record was signed indicating their attendance, understanding and knowledge of future procedures to ensure all medication records have a diagnosis or purpose of medication for all prescription medication, including pro re nata. All program specialists, working managers and nurses will continue to review all medication records to verify and ensure all prescription medication include a diagnosis or purpose for the medication, including pro re nata. (Attachment #1) |
10/19/2023
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.103 | The written emergency evacuation plan did not include the means of transportation. The plan indicated staff were going to transport the individual but did not explain how; i.e. staff vehicle, personal vehicle, company vehicle, etc. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| November 8, 2018- All Program Specialists were trained on their responsibilities that there shall be written emergency evacuation procedures that include individual and staff responsibilities, mean of transportation, and an emergency shelter location. A training record was signed indicating their attendance and understanding. The agency Emergency and Removal Transfer Plan template has been revised to include means of transportation. This new form is a template and is prepopulated to ensure compliance when referencing means of transportation.
November 12, 2018- In all agency homes the Program Specialist updated all Emergency and Removal Transfer plans. They have been verified by the ID Director to be correct and in compliance. |
11/12/2018
| Implemented |
| 6400.112(h) | Previous individual, 1 did not evacuate the residence during the 8/23/18 fire drill. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | November 8, 2018- All Program Specialists were trained on their responsibilities that all individuals should evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. A training record was signed indicating their attendance and understanding. The agency fire drill record has been revised with the addition of instructions that if an individual refuses and/or they do not evacuate within the specified time, the fire drill needs to be done again within the month with documentation.
November 13, 2018- A fire drill was conducted and all individuals evacuated to the designated meeting place outside the building. All fire drill records were reviewed by the ID Director to verify that all individuals have evacuated to a designated meeting place outside the building with the only exception being on 8/23/18 as cited. All agency homes have been reviewed to ensure compliance is being met agency wide. The ID Director will review all agency homes to ensure compliance on a quarterly basis. |
11/13/2018
| Implemented |
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