| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | Individual #1's financial record was not current and up to date. Individual #1's ending balance for August 2022 was $33.05. The beginning balance for September 2022 was $33.01. The ending balance and cash on hand for September 2022 was short by 4 cents. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | The 4 cents were added back to Individual #1's current financial envelope on 9-12-22. All staff were retrained on the importance of correct accounting and math procedures required to balance individual's petty cash accounts. Staff were retrained on the practice of counts of all petty cash accounts. This was completed on 9-12-22. |
10/03/2022
| Implemented |
| 6400.113(c) | At the time of the inspection, there was no documentation that Individual #1 completed fire safety training on 6/20/22, their date of admission. | A written record of fire safety training, including the content of the training and a list of the individuals attending, shall be kept. | The written record was updated with the date fire safety training was completed on 6-20-22. All staff were retrained on the importance of proper documentation and record keeping of training events, specifically fire safety training. This was completed on 9-22-22. |
10/03/2022
| Implemented |
| 6400.141(c)(1) | The most recent physical exam completed on 5/17/22 for Individual #1 does not include a medical history. | The physical examination shall include: A review of previous medical history. | A medical history was attached to the 5-17-21 physical but was not uploaded during the annual licensing inspection. It has since been attached to the annual physical. All staff were retrained on the importance of including an annual and accurate medical history with the annual physical. This was completed on 9-22-22. |
10/03/2022
| Implemented |
| 6400.141(c)(14) | The most recent physical completed for Individual #1 on 5/17/22 does not address the information pertinent to diagnose/treat in the event of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The physician wrote on the physical (see attachment) for diagnoses and other pertinent information required by regulation on the annual physical. The attachment was not uploaded during licensing inspection. It has been added to the annual physical packet as an attachment. Also, all staff were retrained on the need to include all relevant attachments with the annual physical as well as to make sure all annual physicals include medical information pertinent to the diagnosis and treatment in case of emergencies. This was completed on 9-22-22. |
10/03/2022
| Implemented |
| 6400.181(a) | (Repeated Violation -- 3/23/22) Individual #1's date of admission was 6/20/22. The assessment was to be completed by 8/19/22. At the time of the 9/9/22 inspection, the assessment was not completed. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | The assessment was completed and sent out on 9-23-22. Management staff were retrained on 9-23-22 on the requirements and time frames of a new individual moving into the department. All staff were retrained on the requirements of the 60-day assessment and 90 day ISP meeting upon moving in new individuals to the department. |
10/03/2022
| Implemented |
| 6400.18(b)(2) | Individual #1 did not receive their 8pm dose of Famotidine on 8/23/22. To date, this medication error had not been reported to EIM. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person:
A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner. | A med error for the missed 8-23-22 dose of Famotidine at 8pm was entered into the EIM system. Staff were retrained on the importance of timely reporting and specifically med error reporting in the EIM system within 72 hours of discovery. EOCS (Emergency On-Call System) staff were also retrained on the importance of timely reporting and specifically on med error reporting in to the EIM system within 72 hours of discovery. This was completed on 9-22-22. |
10/03/2022
| Implemented |
| 6400.167(a)(1) | (Repeated Violation -- 9/7/21) On 7/4/22, there is no documentation that Individual #1 received their 8pm dose of Quetiapine 200mg. | Medication errors include the following: Failure to administer a medication. | A med error for the missed 7-4-22 dose of Quetiapine 200mg at 8pm was entered into the EIM system. Staff were retrained on the importance of timely reporting and specifically med error reporting in the EIM system within 72 hours of discovery. EOCS (Emergency On-Call System) staff were also retrained on the importance of timely reporting and specifically on med error reporting in to the EIM system within 72 hours of discovery. This was completed on 9-22-22. |
10/03/2022
| Implemented |
| 6400.169(a) | (Repeated Violation -- 3/23/22) Staff person #1 did not complete the required number of observations within the required timeframe for their initial Medication Administration Training timeframe. Staff person #1's initial training indicates that they were fully trained as of 1/21/22, however, because more than 30 days had passed after the written test, which was taken 11/22/21, staff person #1 was required to have 6 observations. This staff person only had 5 when considered fully certified. In order to meet Medication Administration requirements, Staff person #1 would have at to have 9 observations by 5/16/22. To date, this staff person has not completed these observations and must complete the entire Medication Administration course to be qualified to administer medications. Staff person #1 has been administering medications to Individual #1 while uncertified. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | Staff person #1 was instructed to immediately halt administration of medication until they repeat the medication administration training course in its entirety. Staff person # 1 attended the training course on 9-23-22. Staff were retrained on the requirements of medication administration training specifically the requirement to complete the initial practicum within 30 days of the passing of their initial medication training course. |
10/03/2022
| Implemented |