| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(b) | There was an inordinate amount of mouse droppings on the ledge of the wall behind the refrigerators in the kitchen of the home. [Repeat Violation, 5/3/2022] | There may not be evidence of infestation of insects or rodents in the home. | [Immediately, the CEO or designee shall instruct all direct care staff persons/supervisors to complete a walkthrough of each home at least 2 times daily (one being at the end of their shift) to ensure each home is in compliance with regulatory standards to include but not limited to; operable telephones, clean and sanitary conditions, furniture and equipment are in good repair, food is properly stored and protected, garbage is covered and in receptables or removed from the home, cooking and serving utensils are clean and put away, medication is locked, required Individuals' documentation is present, egresses are unobstructed and evidence of infestation of insects or rodents. Training of staff shall include the agency's policies and procedures to ensure the staff person immediately rectifies any issues or the process to report and ensure findings are addressed, timely. Documentation of the home walk through audits shall be kept and reviewed by a management staff person at least weekly. (DPOC by AES,HSLS on 10/18/2022)] |
11/01/2022
| Implemented |
| 6400.64(d) | There was a bag of garbage sitting on the floor in front of the chair in the living room of the home. This bag was removed from the kitchen garbage can and placed on the living room floor. | Trash in the bathroom, dining and kitchen areas shall be kept in cleanable receptacles that prevent the penetration of insects and rodents. | [Immediately, the CEO or designee shall instruct all direct care staff persons/supervisors to complete a walkthrough of each home at least 2 times daily (one being at the end of their shift) to ensure each home is in compliance with regulatory standards to include but not limited to; operable telephones, clean and sanitary conditions, furniture and equipment are in good repair, food is properly stored and protected, garbage is covered and in receptables or removed from the home, cooking and serving utensils are clean and put away, medication is locked, required Individuals' documentation is present, egresses are unobstructed and evidence of infestation of insects or rodents. Training of staff shall include the agency's policies and procedures to ensure the staff person immediately rectifies any issues or the process to report and ensure findings are addressed, timely. Documentation of the home walk through audits shall be kept and reviewed by a management staff person at least weekly. (DPOC by AES,HSLS on 10/18/2022)] |
11/01/2022
| Implemented |
| 6400.112(c) | The written fire drill records for the fire drills completed from February 2022 through September 2022 do not address problems encountered. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | [Immediately, the CEO or designee shall audit the written fire drill documentation to ensure all required information including problems encountered is included on the documentation and revised as needed. Within 2 weeks of receipt of the plan of correction, the CEO or designee shall educate all staff person on conducting fire drills and documenting as required to ensure all required information is included including if problems are encountered and their responsibility if problems are encountered. Documentation of the trainings shall be kept. Upon completion of fire drills, a designated management staff person shall audit all fire drills to ensure fire drills are conducted as required and documented as required to ensure the safety of the individuals and if problems are encountered, they are addressed, timely. Documentation of audits shall be kept. (DPOC by AES,HSLS on 10/18/2022)] |
10/18/2022
| Implemented |
| 6400.141(c)(9) | Individual #1, date of birth 11/30/1954, has not had a prostate examination. | The physical examination shall include: A prostate examination for men 40 years of age or older. | [Immediately, the CEO or designee shall schedule and facilitate Individual #2's prostate testing. Immediately, the CEO or designee shall audit all individuals' current physical examinations to ensure all required information is included including prostate examinations, as required. Immediately, the CEO or designee shall develop and implement a tracking system of individual physical examinations including prostate examination to include the scheduling process with a responsible person, to ensure timely completion of individual's physical examination and other medical appointments. Within 2 weeks of receipt of the plan of correction and continuing at least monthly, the CEO or designee audit the aforementioned tracking system to ensure timely completion of individuals' physical examinations to ensure individuals health services are arranged and provided. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 10/18/2022)] |
11/01/2022
| Implemented |
| 6400.181(a) | Individual #1's assessment was completed on 2/11/2021 and then again on 2/28/2022. | 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. | [Within 2 weeks of receipt of the plan of correction, the CEO or designee shall develop and implement a tracking system to ensure all individual's assessments are completed, timely, and provided to the plan team members, timely and to maintain documentation. At least monthly for one year and then continuing at least quarterly, the CEO or designee shall audit the aforementioned tracking system and related documentation to ensure assessments are completed with all required information, timely and provided to plan team members, timely. (DPOC by AEs,HSLS on 10/18/2022)] |
11/01/2022
| Not Implemented |
| 6400.181(e)(4) | Individual #1's assessment, completed 2/28/22, does not include Individual #1's need for supervision. | The assessment must include the following information: The individual's need for supervision.
| [Immediately, the program specialist shall complete Individual #1's assessment to include all required information. Within 2 weeks, and upon completion for at least one year, the CEO or designee educated in the requirements of Individuals' assessments, shall audit all individuals' current assessments to ensure all required information is included and accurate. Documentation of audits shall be kept. (DPOC by AES,HSLS on 10/18/2022)] |
11/01/2022
| Not Implemented |
| 6400.166(a)(7) | Individual #1's October 2022 Medication Administration Record does not include the dosage for Extra Strength Pain Relief. [Repeat Violation, 5/3/2022] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | [Within 2 weeks of receipt of the plan of correction, and continuing at least monthly and upon all individuals' medication changes, a designated staff person qualified to administer medications shall audit all individuals medications, current medications administration record and prescribed medications including over the counter medications to ensure all individual are administered medications as prescribed, current medication administration record is accurate and medication administrations are documented as required. Documentation of audits shall be kept. (DPOC by AES,HSLS on 10/18/2022)] |
11/01/2022
| Not Implemented |