| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(a) | At time of inspection the water temperature in the main bathroom of the home was 100 degrees. The home shall have hot running water. | A home shall have hot and cold running water under pressure. | The agency Maintenance Staff adjusted the hot water heating unit to be in compliance with the 120 degree regulatory requirement. |
04/14/2022
| Implemented |
| 6400.110(f) | The Individual Support Plan for Individual #1 with an update date of 4/19/22 indicates that "Due to being blind & deaf she would not be able to see or hear if something is happening." The emergency information sheet for Individual #1 states that they are blind and deaf. Smoke detectors were in working order and within regulation at the time of inspection, but the system was not equipped so that each person with a hearing impairment will be alerted in the event of a fire. All smoke detectors and fire alarms in the home shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. | If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. | The agency is searching for a personal vibrating device to alert the individual in the event the smoke detector/ fire alarm system is activated. This agency home is staffed with 24/7 awake staff that provide assistance to the individual to evacuate the home in the event of a fire. |
06/30/2022
| Implemented |
| 6400.141(c)(4) | Individual #1 had an annual physical completed on 7/14/21. The hearing section on the physical was blank. There was no additional documentation to indicate that an annual hearing exam had been completed. Annual hearing screening is required to fulfill regulatory requirements. | 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 reviewed the documentation and the practitioner has indicated the hearing screening has been completed-Please see the attached Document for review. |
05/24/2022
| Implemented |
| 6400.141(c)(7) | Individual #1 had an annual gynecological exam completed on 12/3/2020. There was no additional documentation to indicate that an exam had been completed to fulfill the annual requirement for 12/2021. There was no documentation from a licensed physician recommending no or less frequent gynecological exams. Annual exam is required unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | 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. | The individual's previous PCP and the GYN were in agreement that this individual would best be served by an ultrasound detection for the required breast examination and that the Pap Test was not necessary due to lack of family history of illness and the individual being sexually inactive. The agency has taken the individual for the gyn appointment and is awaiting the results at this time. |
06/30/2022
| Implemented |
| 6400.141(c)(8) | According to regulation Individual #1 currently requires a mammogram every two years. Documentation of an ultrasound of their breast being completed on 12/23/21 was part of the Individual's record. Ultrasound is not an acceptable substitution. There was no record of a mammogram being completed at any time nor further documentation from a licensed physician that the examinations are not required based on the individual's physical condition or based on standards of care. Documentation of completion of a mammogram or documentation from a licensed physician that the examinations are not required based on the individual's physical condition or based on standards of care is required to fulfill regulation. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | The individual's previous PCP and the GYN were in agreement that this individual would best be served by an ultrasound detection for the required breast examination and that the Pap Test was not necessary due to lack of family history of illness and the individual being sexually inactive. The agency has taken the individual for the gyn appointment and is awaiting the results at this time. |
06/30/2022
| Implemented |