| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | Individual #4's financial record is not current and up to date. Individual #4's financial record had a beginning balance of $1633.95, there were two purchases indicated on the record, Trinity Pharmacy on 1/3/22 for $5.38 and Amish View July 25 on 1/11/22 for 1,367.52, leaving the individual with $266.43. There were then withdrawals/purchases documented for Amish View, Aug 22,22 on 1/11/22 in the amount of $1434.12, Amish View Sept. 19, 22 on 1/11/22 in the amount of $1411.92, Personal spending on 1/14/22 in the amount of $10 and Pharamerica on1/17/22 in the amount of $97.70, leaving Individual #4 with a negative balance of $2,687.31. This balance carried forward to February when there were additional withdrawals/purchases at Sam's Club on 2/1/22 in the amount of $31.68, Pharamerica on 2/2/22 for $180.35, Sam's Club on 2/18/22 for $268.08, Personal Spending on 2/18/22 $20 and Walmart on 2/19/22 for $24.36 leaving the ending balance in February negative $3,239.78. This balance carried over to March with further withdrawals/purchases in the amounts of $1,156.20 on 3/9/22 for Homewood Suites for a 6/7/22 trip; Pharamerica on 3/15/22 for $171.43, Personal Spending on 3/18/22 $10 and credits of $4000 on 3/23/22 and $700 on 3/28/22 creating an ending balance of $122.59. There not receipts for the January 11, 2022, withdrawals/purchases of $1367.52; $1434.12; $1411.92; for the March 9, 2022, $1,156.20 withdrawal. The individual only had $122.59 cash available. The provider indicated that the 1/11/22 and 3/9/22 amounts were not paid for therefore there are not receipts available. The provider booked the trips for the individual and the money was withdrawn from the individual's bank account and placed in an agency recreation fund to pay for the trips when they occur. The provider indicated that this is done in order to prevent the individuals account from exceeding amounts allowed by social security in order to prevent the individual from losing their benefits due to having too much money. The provider is not maintaining an accurate and up to date financial record of the individual's funds. | 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. | Individual's Financial and Property Records will be maintained utilizing the guidance and suggestions shared by the licensing inspectors ensuring compliance with the regulations. |
05/26/2022
| Implemented |
| 6400.22(e)(3) | Receipts are not being maintained for purchases over $15 on behalf of the individual. Individual #4's January financial record indicated that purchases were made on January 11, 2022, in the amounts of $1,367.52 for Amish View July 25, 22; $1,434.12 for Amish View Aug 22,22; $1411.92 Amish View Sept. 19, 22. Individual #4's March 2022 financial record indicated a purchase on 3/9/22 in the amount of $1,156.20 for Homewood Suites for a trip on 6/7/22. There were no receipts of these purchases. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | Individual's Financial and Property Records will be maintained utilizing the guidance and suggestions shared by the licensing inspectors ensuring compliance with the regulations. |
05/24/2022
| Implemented |
| 6400.22(f) | The provider is commingling individual funds. Individual #4 had withdrawals 3/2/22 in the amount of $621.43, 2/23/22 in the amount of $4,000 and on 3/28/22 in the amount of $700 from the individuals bank account. This cash was not available and there were no receipts for purchases totaling $5321.34. When questioned, the provider indicated that the money is deposited into an agency recreation account to pay for trips that are booked for June-September. The recreation account is utilized for all individuals participating in the trips. | There may be no commingling of the individual's personal funds with the home or staff person's funds. | The agency will no longer maintain the account which has been deemed non-compliant with the regulations. |
05/24/2022
| Implemented |
| 6400.64(f) | Two of three trash cans outside of the home did not contain lids. The third trash can had a lid, however the lid was not covering the can, it was inside the can that contained a bag of trash. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | The agency Maintenance Staff removed the lid from inside the can and placed it properly on top of the container. |
04/14/2022
| Implemented |
| 6400.68(a) | The water temperature in the home was 96 degrees. | A home shall have hot and cold running water under pressure. | The agency Maintenance Staff adjusted the temperature on the water heating unit to be in compliance with the 120 degree regulatory requirement. |
04/14/2022
| Implemented |
| 6400.77(b) | The first aid kit in the home did not contain tape. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | The agency staff placed a roll of the tape required in the First Aid Kit to meet the regulatory requirements. |
04/14/2022
| Implemented |
| 6400.141(c)(4) | Individual #4's annual physical examination dated 8/30/21 did not include a hearing examination. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | The agency has reached out to the PCP provider to obtain the proper information and services as required by the regulations. In this case a separate hearing examination will be performed with results to follow. |
06/30/2022
| Implemented |
| 6400.141(c)(6) | Individual #4's annual physical dated 8/30/21 did not include a Tuberculin(TB) skin testing by Mantoux method. Individual #4's TB test was dated 3/18/22. The TB test was due by 11/19/21. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | The agency has reached out to the PCP to ensure a better timeline of compliance to meet the regulatory requirements. |
04/14/2022
| Implemented |
| 6400.141(c)(14) | Individual #4's annual physical dated 8/20/21 did not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The agency reached out to the PCP and verified the correct information which was then placed on the document. This information was overlooked previously by the PCP and agency. |
04/14/2022
| Implemented |