| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.80(b) | The steps that go from the basement door exit were full of moss and wet leaves which could lead to unsafe conditions. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The Provider will ensure the building and yard shall be well maintained, in good repair and free from unsafe conditions. To correct immediately, a maintenance work order was submitted and completed to remove debris. |
10/28/2022
| Implemented |
| 6400.142(f) | Individual #3 did not have a dental hygiene plan written. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | The Provider will ensure all consumers shall have a written plan for dental hygiene as required. |
10/20/2022
| Implemented |
| 6400.52(c)(5) | Staff #5 did not have documentation that supports they had annual training in safe and appropriate use of behavior supports. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | During the annual QA&I process, this provider found that tenured staff did not have the required annual safe and appropriate use of behavior supports training. To ensure immediate compliance, this provider's training director assigned "Positive Behavior Supports" to all tenured staff on 8/31/22. All staff had 30 days to complete. All new hire staff are assigned at the time of hire. This staff completed the training on
8-29-22. |
08/29/2022
| Implemented |
| 6400.52(c)(6) | Staff #5 did not have documentation that supports they had annual training in the implementation of the ISP. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | All staff shall have annual training in the implementation of the ISP. |
03/01/2022
| Implemented |
| 6400.166(a)(13) | At the time of the inspection individual #3 was given his medication vitamin D in the morning, but staff did not initial the medication administration record. The pill count reflects the correct number of pills as if the medication was administered correctly, however the staff forgot to initial the MAR. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | The Provider will ensure all staff received proper and adequate training in Medication Administration, including signing the MAR and documenting with initials the person administering the medication. |
10/13/2022
| Implemented |
| 6400.182(c) | Individual #3 ISP under the section of learning/cognitive it reflects that he has minimal understanding of money management. However Individual #3 annual assessment dated 7/9/2022 reflects that he is recognizes money, understands money, can identify coins and currency, is able to manage finances and spending for the week. The ISP should have that reflected as the assessment determines he is able to manage his own finances. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The Provider will ensure the individual's plan is developed and revised when the individual's needs change based upon a current assessment or at least annually. |
10/20/2022
| Implemented |