| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | All individuals in the home were not poison aware therefore all poisonous materials should have been locked. There were a few large cans of paint in the garage not locked away or made inaccessible to individuals. There was also a packet of room freshener that was unlocked in the closet in the basement hallway. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The paint cans were moved to the locked closet beneath the stairway in the garage the evening after inspection. The packet of room freshener that was unlocked in the closet in the basement hallway was also moved into the closet with other poisons and locked. Going forward, the Associate Director of the home will ensure all poisons are appropriately locked. See picture of paint cans all in closet under stairs (attachment # 8) |
07/09/2015
| Implemented |
| 6400.71 | The telephone in the bathroom did not contain, or list nearby, the numbers of the nearest hospital, police department, fire department, ambulance, and poison control center. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| The numbers of the nearest hospital, police department, fire department, ambulance, and poison control center were added to the telephone the evening after the inspection. In the future, the Associate Director will check on each house visit to ensure the numbers are on the phone and clearly visible and readily available to staff in the event of emergency. See attachment 8. |
07/09/2015
| Implemented |
| 6400.103 | The written evacuation procedures for all the individuals in the home did not contain their individual responsibilities. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| There are written emergency evacuation procedures that include staff responsibilities, means of transportation and an emergency shelter location. Our procedures did not include specific emergency procedures for each person. An emergency plan was developed for each home listing the individual responsibilities during an emergency. See attachment 7. This plan of individual responsibilities is now filed in the fire log and the Associate Director is responsible for ongoing monitoring of the responsibilities to ensure they are current and updated.
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07/21/2015
| Implemented |
| 6400.162(a) | Individual #1's medication label for Enema stated that it was to be used as: "use 1 Enema every 2 days if no bowel movement (between 5pm and 7pm)". Staff were administering the medication every 3 days if Individual #1 did not have a bowel movement. The medicaiton label was not clear how often to administer the medication, how long in between each bowel movement, and at what time it was to be administered. | 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. | The doctor's orders are to give an enema every 3 days. The enema label was challenging to read. Staff asked the pharmacy for a label that says "Give 1 enema between 5p-7pm on day 3 if no bowel movement for 72 hours" to match the Dr.'s orders. See attachment 6-C for label. Ongoing monitoring of labels matching med logs will be completed by Associate Directors on house visits. |
07/20/2015
| Implemented |
| 6400.164(a) | An Enema was administered to Individual #1 on 7/1/15 and 7/5/15 however there was no medication log for each administration. The medication label for Depakote that was prescribed to Individual #1 stated it was to be administered at 8am, 12pm, 4pm and 9pm. The medication logs for Depakote stated that the medication was to be administered at 8pm. | 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. | The enema is now charted on medication logs. The staff completed the July medication log with the record of errors sheet (See attachment 6 for MAR's and error sheet). A medication log since inspection is also included (attachment 6-A). Ongoing monitoring by the Associate Director on house visits will be done to include checking all medications are on medication logs. The Depakote label and the Depakote medication logs now match as of 8/1/15. See attached medication logs and medication labels (Attachment 6-B) of a log since inspection (October logs). The Associate Director of the home will monitor medication labels against medication logs to ensure labels match. |
08/01/2015
| Implemented |
| 6400.181(e)(13)(vii) | The assessment for Individual #1 did not include their progress and current level in financial independence. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| The program specialist corrected the current assessment and sent out a memorandum to all team members (see attachment # 2) notifying them of the correction to the assessment. Examples of assessments since licensing are also attached (see attachments #3 & # 4). Going forward the Program Specialist will be responsible for ensuring the progress and current level in financial independence that occurred over the last 365 calendar days is documented in the financial progress section of the assessment. |
07/14/2015
| Implemented |
| 6400.181(e)(13)(ix) | The assessment for Individual #1 did not include their progress and current level in community-integration. This section was missing from the assessment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration. | The program specialist corrected the current assessment and sent out a memorandum to all team members (see attachment # 2) notifying them of the correction to the assessment. Examples of assessments since licensing are also attached (see attachments #3 and # 5). The progress for community integration was added to the master blank assessment and to all current individuals' assessments. |
07/14/2015
| Implemented |
| 6400.213(11) | Individual #1's medication history stated that Individual #1 was on a low salt, low carbohydrate, and low cholesterol diet. Individual #1's Individual Support Plan (ISP) stated they were only on a diet to have their food cut into dime-size pieces. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | Individual #1's physician sent a clarification regarding the diet for Indiviudal #1 (attachment # 1). All of our forms matched the individuals physical and ISP. A doctors printout from an appointment on 2-26-15 (attachment 1-A) had information that did not match. In the future, the program specialist will review print outs from the doctor's office to ensure all medication and information is matching our current record and if not, follow up clarification for the correct orders will be reviewed with the doctor. |
07/21/2015
| Implemented |