| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.64(a) | The wall and floor behind Individual #1's bed is seen to have what appeared to be fluid spilled down the walls and onto the floor. This surface is extremely unclean in that area. | Clean conditions shall be maintained in all areas of the home. | On 3/20/24, the Chief of Community Integration cleaned the stain off of the wall and floor of the individual¿s bedroom (Attachment 5). House checks at all homes were completed on 3/20/24 and 3/21/24 by the Chief of Community Integration showing that all walls and floors were free of stains and any other unsanitary conditions (Attachments 1 and 2). |
03/21/2024
| Implemented |
| 6500.124 | Individual #1 is prescribed Docusate Sodium Capsule, 100mg. Directions on January and February 2024 MAR state to take 1 capsule by mouth daily, as needed for constipation. There is no additional directions or plan in place that specifies what "as needed for constipation" means. It is unknown if the prescribed medication is to be taken if a certain number of hours have passed since the last bowel movement, or if the Individual is to advise that they are in discomfort, etc. Additionally, there are no directions on what the provider is to do if the prescribed Docusate Sodium capsule is unsuccessful. In February 2024, Individual was administered Docusate Sodium capsules 4 days in a row (2/10 -- 2/13/), there is no plan or direction identifying at what point should the prescriber be contacted if medication is not successful. | 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. | On 3/19/24, the Chief of Community Integration sent a message to the individual¿s healthcare provider asking for clarification on when the prn medication should be given. The healthcare provider responded with parameters for when the medication should be given (Attachment 6). A training with the individual¿s Lifesharing provider on the recommendations for when to take the medication was completed by the Chief of Community Integration on 3/20/24 (Attachment 7). An email was sent to the individual¿s supports coordinator asking that this information be added to the ISP by the Chief of Community Integration on 3/20/24 (Attachment 8). A review of all individual¿s prn medications was also completed by the Chief of Community Integration on 3/20/24 showing that all prn medications clearly state when to administer the medication (Attachment 9). |
03/20/2024
| Implemented |
| 6500.152(c) | Individual #1's assessment dated 2/23/2024 states that they are not safe around poisonous substances. Individual's ISP dated 1/23/2024 states that poisons are to be kept out of reach. The ISP should reflect the Individual's needs based off the current assessment. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | During the inspection on 3/19/24, an email was sent to the individual¿s supports coordinator by the Chief of Community Integration asking if the ISP can be updated to say that poisons aren¿t kept out of reach, they are locked in the home (Attachment 3). A review of all individual¿s ISPs and assessments were completed by the Chief of Community Integration on 3/20/24 showing that the poison safety sections matched (Attachment 4). |
03/20/2024
| Implemented |