| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | A self-assessment of the home was not completed. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| An assessment was completed and sent to BHSL for review. In the future the Program Specialist or designee will complete a self-inspection 3 to 6 months prior to the date of the annual inspection. |
10/31/2014
| Implemented |
| 6400.22(c) | Individual # 1 had four items of a pharmaceutical nature billed to his personal account: 6/13/13 non-adherent pads, kerlix gauze, stethoscope classic II, and on 6/18/13 sharps cont-1 gall, and alcohol pre pad. Approximate billed amount: $109.84 were not for Individual #1. | Individual funds and property shall be used for the individual's benefit. | The expenses were reimbursed from Peaceful Living to individual #1. The Program Specialist or designee will conduct montly audits of all Individuals financial accounts to ensure that items are not inappropriately billed and that receipts are available for all expenses, starting within 30 days of receipt of this plan of correction. The staff of the home will receive training on the importance of maintaining accurate financial records within 30 days of receipt of this plan of correction. [SW 1.20.15] |
10/08/2014
| Implemented |
| 6400.76(a) | Individual #2's bedroom dresser had a broken knob. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The dresser knob was replaced. The Program Specialist or designee will conduct monthly physical site inspections of all homes to ensure that furniture and equipments is in good repair starting within 30 days of receipt of this plan of correction. [SW 1.20.15] |
09/30/2014
| Implemented |
| 6400.151(c)(2) | Staff # 1, date of hire 10/09/13, did not receive the Tuberculin skin test until 11/04/13. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | Our hiring system was checked and reviewed and staff are not permitted to attend agency orientation until their physical/mantoux is complete. The Director will audit all employee records to ensure that Tuberculin tests have been completed timely. |
10/30/2014
| Implemented |
| 6400.162(a) | Individual # 1 has Clotrimazole and Guaifenesin prescribed for prn administration; the medications were not labeled with the individuals name. | The original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. | All prn medications are now specifically labeled for each person supported. Individual #1's medications were labeled within their name. The Program Specialist will conduct monthly audits of the medications to be administered to Individuals of the home, to ensure that required labeling is complete, starting within 30 days of receipt of this plan of correction. |
10/20/2014
| Implemented |
| 6400.164(a) | Individual # 1 was prescribed Gimepride; this medication was not available for administration. | A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. | Th prn medication, for Individual #1, was refilled and is now available for administration if needed. The Program Director will conduct monthly audits of the medications available for administrations, to ensure that all PRN and daily medications are available, starting within 30 days of receipt of this plan of correction. Staff will receive training on the importance of the availability of all prescribed medications within, 30 days of receipt of this plan of correction. [SW 1.20.15] |
09/29/2014
| Implemented |