| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.76(a) | The Seat cushion on the right dining chair when coming from the living area was not secured to the chair. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The Seat cushion on the right dining chair when coming from the living area was not secured to the chair. A work order was put in with facilities to repair the chairs in the dinning room. The chairs were fixed by facilities.Staff received an additional onsite orientation to review required cleaning standards per the regulations. Site checks will be completed twice weekly, and results will be turned into the Program Director for review and follow up on items that need to be addressed and corrected. House managers will check the cleanliness of the entire home during site checks while completing weekly environmental checks of the site. |
05/12/2022
| Implemented |
| 6400.141(c)(7) | A (GYN) gynecological examination including a breast examination and a Pap test for Individual 2 was not listed as conducted on the annual physical examination form dated 04/16/2021 and prior exam form dated 04/27/2020 as this portion was left blank on both exams. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | A (GYN) gynecological examination including a breast examination and a Pap test for Individual 2 was not listed as conducted on the annual physical examination form dated 04/16/2021 and prior exam form dated 04/27/2020 as this portion was left blank on both exams.K. Mullins annual GYN exam was completed on 5/5/22, but she refused her PAP. A refusal form was completed on 5/5/22 and a desensitization plan was implemented on 5/6/22. KM next PAP appointment is scheduled for 5/26/22 for a second attempt. |
05/26/2022
| Implemented |
| 6400.141(c)(13) | On the annual exam form dated 04/16/2021 the portion indicating if Individual 2 has allergies was left blank. | The physical examination shall include: Allergies or contraindicated medications. | On the annual exam form dated 04/16/2021 the portion indicating if Individual 2 has allergies was left blank.K. Mullins annual physical exam was completed on 4/7/22. The examination form was completely filled out to reflect that she has allergies/sensitivity to Depakote and seasonal allergies. K. Mullins is rescheduled to return in 1 year. |
04/08/2022
| Implemented |
| 6400.141(c)(14) | Medical information pertinent to diagnosis and treatment in case of an emergency was left blank on the physical examination form dated 04/16/2021 for Individual 2. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Medical information pertinent to diagnosis and treatment in case of an emergency was left blank on the physical examination form dated 04/16/2021 for Individual 2.K. Mullins annual physical form has been corrected to reflect medical information pertinent to diagnosis and treatment in case of an emergency on 4/7/22. It is noted to follow up with VOADV.Program specialist will track annual appointments quarterly when completing quarterly appointments. The Nurse will review all medical appointment documentation to ensure the forms are properly filled out prior to filing in individuals medical charts. The Department Director will audit the program charts quarterly to ensure all required documentation is present, accurate, and completed correctly. Any items found to need follow up will assigned to the Program Specialist to complete with a 5 day turn around resubmission to the Department Director prior to filing in the program charts. |
04/08/2022
| Implemented |
| 6400.141(c)(15) | Special instructions for the Individual 2 diet instructions were left blank on the exam dated 4/16/21. | The physical examination shall include:Special instructions for the individual's diet. | Special instructions for the Individual 2 diet instructions were left blank on the exam dated 4/16/21.K. Mullins physical was corrected on 4/7/22 to reflect a low sodium dietThe Nurse will ensure that all of the required documentation for refusals will be present in the charts following any refusal of an appointment. Program specialist will track annual appointments quarterly when completing quarterly appointments. The Nurse will review all medical appointment documentation to ensure the forms are properly filled out prior to filing in individuals medical charts. The Department Director will audit the program charts quarterly to ensure all required documentation is present, accurate, and completed correctly. Any items found to need follow up will assigned to the Program Specialist to complete with a 5 day turn around resubmission to the Department Director prior to filing in the program charts |
04/08/2022
| Implemented |
| 6400.142(a) | Individual 2 did not have a dental examination performed by a licensed dentist annually. Previous exam was conducted on 06/12/2019 and most current examination was conducted 01/26/2022. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Individual 2 did not have a dental examination performed by a licensed dentist annually. Previous exam was conducted on 06/12/2019 and most current examination was conducted 01/26/2022. Due to covid-19 Individual 2 did not want to complete their Dental appointment. A refusal of appointment form should have been completed and placed in the medical chart per policy to keep track of follow up needs with appointments. Once Individual #2 felt comfortable with completing the appointment an in office appointment was scheduled and completed on 1/26/2022.The Nurse will ensure that all of the required documentation for refusals will be present in the charts following any refusal of an appointment. |
04/08/2022
| Implemented |
| 6400.144 | The Glucose sugar readings for Individual 2 did not match the glucose records kept in the log book. On 4/3, the glucose device recorded a blood sugar level of 67 on the PM reading but log book no, dated 129. On 4/1, the device read 108 but was logged as 136. On 4/5 the device read 154 but was logged as 151. | 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.
| The Glucose sugar readings for Individual 2 did not match the glucose records kept in the log book. On 4/3, the glucose device recorded a blood sugar level of 67 on the PM reading but log book no, dated 129. On 4/1, the device read 108 but was logged as 136. On 4/5 the device read 154 but was logged as 151.Training was completed with K. Mullins and Lead DSP on 4/7/22 on how to properly use his blood sugar monitor and communicate the correct reading to staff to document as well as implement a two-step check process by staff to ensure the sugar was taken correctly and then document the correct numbers. |
04/08/2022
| Implemented |