Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6500.62(a) | The current Individual Support Plan (ISP) dated 9/08/2021 for Individual #2 states that the individual is "not able to handle or avoid all poisonous substances such as detergents, cleaners, medications and automotive products." Several cleaning and automotive products including "Goo Gone" (label states to contact poison control if ingested) and "Armor All" were found in an unlocked and accessible cabinet in the kitchen. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Poisonous substances including all cleaners and automotive products including "Goo Gone" and :"Armor All" were removed from unlocked areas and placed in locked areas. All members of the lifesharing family including the LSP's children will be retrained/trained in the handling and storage of poisonous materials |
11/10/2021
| Implemented |
6500.32(i) | At the time of the inspection, Individual #2 had no clothes in the individual's bedroom closet or dresser. Staff #1 (the Family Living Provider) opened a locked closet in the hallway where all of the Individual's clothing was kept. Staff #1 stated that if the clothes were not locked up, the individual would put clothes on and take them off at all hours of the day and night. The individual's current Individual Support Plan does not document this behavior or the need to keep the individual's clothing locked and inaccessible. There is no restrictive procedure plan in place. This violates the Individual's right to access to their possessions. | An individual has the right of access to and security of the individual's possessions. | Individual #2 has had her seasonally appropriate clothing returned to her bedroom. The life sharing providers have been retrained on individual rights including the right of the individual to have access to her possessions. The team will meet to discuss whether or not is is necessary to implement a restrictive procedure or whether or not a non-restrictive behavioral plan can be developed and implemented to discourage Individual #2 from constantly changing her clothes. |
11/10/2021
| Implemented |
6500.32(r)(1) | There was no locking mechanism on Individual #1's bedroom door. Staff #2 (the Family Living Specialist) stated that the individual did not want a door lock and had stated so when asked at the time that the annual rights and releases packet was reviewed and signed. Staff #1 (the Family Living Provider) stated that the individual had told the provider that the individual does want a lock on the bedroom door. This information is not documented in the Individual Support Plan. | An individual has the right to lock the individual's bedroom door. Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | The team will meet with Individual #1 to review with and educate her the right to have a lock on her bedroom door and her right to change her mind about having or not having a lock. at any time. This meeting and outcome of the meeting will be added into her ISP. |
11/10/2021
| Implemented |
6500.136(a)(11) | The October 2021 medication administration record (MAR) for Individual #2 did not include a diagnosis or purpose for the medications Loratadine and Vitamin D. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | The diagnosis or purpose for the medications Loratadine and Vitamin D has been added to the October 2021 medication log for Individual #2. |
11/20/2021
| Implemented |