| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(c) | The self- assessments completed for the homes had identified violations. However, the provider did not have any documentation detailing the violation or a summary of corrections made to fix the violations for any of the homes. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| An internal Plan of Correction was created to use when doing a self assessment. The document list the Regulation, description, what action is required and who is responsible |
10/12/2021
| Implemented |
| 6400.22(d)(1) | For Individual #1 the "Strong Box Log" (financial ledger) states that on 7/01 there was a deposit from individual #1's mother of $80 for a total new balance of $123.75. However, no where on the ledger was it notated the beginning balance for the month. This information needs to be documented to verify new balances from debits and deposits. Upon review of the ending balance from the previous month, the amount listed as the ending balance on 6/27/2021 was $33.98. The first deposit on July 1 was for $80. The total should have been $113.98, however the new balance listed after the deposit was $123.75. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | A new Individuals Financial Ledger Document was recreated to include the month of the ledger and the beginning balance from the month before in order to have an accurate balance to start with. The document is also more descriptive with asking staff to note whether the Amount was a Deposit of money or a withdraw. (See attachment #1) |
10/12/2021
| Not Implemented |
| 6400.22(d)(2) | Sometime between 6/27/2021 and 7/01/2021 there was a deposit of $9.77 in order for the new balance to have been $123.75. The ending ledger notated that individual #1 had $2.29 in cash. The picture confirmed that was the exact amount in the lock box. Therefore, there is a missing deposit that was not recorded on the financial log for Individual #1 | (2) Disbursements made to or for the individual.
| A new financial ledger has been created for staff to document where, when, and how much money was spent. This new document asks staff to note whether the amount of money in the account was a deposit or a withdraw. (See attachment #1) |
10/12/2021
| Implemented |
| 6400.67(a) | The kitchen drawer to the left of the stove would not open the whole way. The drawer would bang against the stove, preventing it from opening the entire way. The drawer only came open about a third of the way. | Floors, walls, ceilings and other surfaces shall be in good repair. | The maintenance supervisor removed the drawer and put in a false front to eliminate the drawer. (See attachment #2) |
10/12/2021
| Implemented |
| 6400.112(c) | The fire drill records from 8/31/2021, 7/13/2021, and 12/20/2020 did not indicate whether the fire drill occurred in the am or pm. (For example, it just said "11:00"; not indicating whether it was 11 am or 11pm).
The fire drill from 3/11/2021 did not indicate the amount of time it took for evacuation. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | The team will go over the fire drill document and recreate in the event that it is too complex to fill out by the supervisory staff. The supervisory staff will be trained on the regulations and the Associate Director will demonstrate the proper way to document a fire drill. |
10/12/2021
| Implemented |
| 6400.112(d) | The fire drill held on 3/11/2021 did not indicate that the evacuation time therefore it cannot be determined if the evacuation time requirement of 2.5 minutes was met according to regulation 6400.112.d.
The fire drill was not repeated that month in order to demonstrate compliance with this regulation. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employee of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | A fire drill schedule will be created to unsure the fire drills are done at the beginning of the month. The fire drill will be conducted by a supervisor. The supervisor to conduct the fire drill will be trained on how to appropriately fill out the fire drill form and what to do in the event the fire drill can not be completed to its entirety. |
10/12/2021
| Implemented |
| 6400.141(c)(1) | The most recent physical dated 12/09/2020 for individual #1 states that the individual "is able to feed [individual #1 self] finger foods". For a review of past medical history, it is acceptable to state that the individual "was able to feed [individual #1's own self] finger food" but clarify that individual #1 is now on a pureed diet. This information was prepopulated for the DR to sign off on that he reviewed the information in the section of "present and previous medical history. This information was not accurate to individual #1's current health/nutrition needs. | The physical examination shall include: A review of previous medical history. | A training will be done with all supervisory staff on how a physical form will be filled out and that they should be filled out on the day of the appointment according to the current and accurate information of the individual. |
10/12/2021
| Not Implemented |
| 6400.141(c)(15) | The most recent physical for individual #1 dated 12/09/2020 states that the individual is on a "ground diet with honey thick liquids", but the Dr orders from individual #1's swallow study from 9/30/2020 indicated that the individual should be on a "pureed diet". A pureed diet is a different consistency from a ground diet. | The physical examination shall include: Special instructions for the individual's diet. | The associate director will assist supervisory staff in filling out the physical form according to accurate information from previous appointment, and current ISP. |
10/12/2021
| Implemented |
| 6400.144 | Individual #1 has a history of seizures that is controlled by medication. Individual #1 was also evaluated through a swallow study on 9/30/2020 where individual #1 was evaluated as a high choking risk and diet was changed to a pureed diet with honey thick liquids. individual #1 was also seen in the hospital from 10/05/2020 to 10/09/2020 for aspiration Pneumonia, where the hospital again gave discharge instructions for a pureed diet and honey thick liquids.
As of the date of this inspection, there was no seizure plan or protocol nor was there documentation of staff training on a seizure protocol. There was also no plan or protocol for individual #1's nutrition plan of a pureed diet and honey thick liquids. There was also no documentation demonstrating that staff who work in this home have been trained on this protocol.
It has been almost a year since the change in individual #1's diet and individual #1 has had a history of seizures since admission with the provider since 8/20/1984, and there are no plans or protocols in place.
Individual #1's most recent assessment dated 10/06/2020 indicates inconsistencies of diet, stating "ground" instead of "pureed" as well as the most recent physical dated 12/09/2020 and both documents were created after the new diet change occurred in September of 2020.
All of these factors indicate that health services are not being planned for appropriately as prescribed and this puts the individual at a high risk of potential neglect. | 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.
| A new training is being created for individuals with a hx of seizures, aspiration, constipation, and choking. The training will be specific to the individual and their health needs. |
10/12/2021
| Not Implemented |
| 6400.181(e)(1) | The most recent assessment for individual #1 dated 10/06/20 states that, ["individual #1] can self-feed finger foods". However, as of 9/30/2020 Individual #1's diet changed to pureed diet with honey thick liquids. The assessment was not updated to reflect the individual's current needs. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | A new assessment was completed on 10/7/2021 to reflect the changes to the individuals by the Program Specialist. (See attachment #3) |
10/12/2021
| Implemented |
| 6400.181(e)(3)(ii) | On individual #1's rights and releases paperwork, staff wrote "refused to sign" but through further investigation, it was determined that the individual did not refuse to sign the documentation, but rather is unable to sign or make a "mark". This assessment of individual #1's written communication abilities was not included in the most recent assessment dated 10/06/2020. | The assessment must include the following information: The individual's current level of performance and progress in the following areas: Communication. | A new assessment was completed 10/7/2021 to reflect the changes to the individuals current level of performance and progress on Communication by the Program Specialist. (See attachment #3) |
10/12/2021
| Implemented |
| 6400.181(e)(3)(iv) | Individual #1's most recent assessment dated 10/06/2020 states that individual #1 is on a "ground diet". As of 9/30/2020, the individuals diet changed to "pureed diet". This information was not updated to reflect the individuals most current needs. | The assessment must include the following information: The individual's current level of performance and progress in the following areas: Personal needs with or without assistance from others. | The Program specialist created a new assessment on 10/07/2021 to reflect the changes to the individuals current level of performance and progress with personal needs to indicate if the individual can do tasks with or without assistance. (see attachment #3) |
10/12/2021
| Implemented |
| 6400.34(a) | The rights form did not contain all of the individual rights information afforded to the individuals according to regulation 6400.32a-v.
The form was specifically missing regulations:
31a Deprived of Rights
31c Exercise Rights -- punishment
32f Refusal of Activities
32i Access/Security of Possessions
32p Choice of Roommate
32q Furnish/Decorate Bedroom, common area
32r2 Access to Bedroom
32r3 Access to Technology
32r4 Immediate Access
32r5 Staff Key
32s Entry Mechanism -- Front Door
32s1 Assistive Technology
32s2 Immediate Access
32s3 Staff Key
32t Access to Food
32u Health Care Decision
32v Rights modified
33a
33b | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | On 9/27/2021 A new individual Rights form was created to contain all of the information that is listed in the 6400 regulations.32a-v. This document was read to individuals and signed. This form will be utilized in the future for any new individuals and annually thereafter. |
10/12/2021
| Implemented |
| 6400.34(b) | The individual rights documentation in individual #1's chart had written on the form "refused to sign" however upon further review it was determined that the individual did not refuse to sign the documentation, rather individual #1 is incapable of signing or making a "mark". In such case, the provider should notate "unable to sign" on the form and request that individual #1's emergency contact, in this case the mother, to sign for individual #1 as a representative. | The home shall keep a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights. | An individuals rights form was reviewed with the individuals mother via phone and was mailed to her to sign with a return envelope. Upon return the Individual rights form will be placed in the individuals permanent chart. |
10/12/2021
| Implemented |
| 6400.182(c) | The most current ISP for individual #1 dated 11/20/2020 under "health evaluations" has a dental plan written that is not current or up to date. Individual #1 had all teeth extracted on 5/25/20 and Peridex 0.12% solution was discontinued. This information was not updated in the last ISP. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | An ISP correction form was created to utilize if changes are made to the individuals needs or level of care. The document was completed on 10/11/2021 to reflect the changes to the individuals dental plan and was emailed to the Supports Coordinator. (See attachment # 5) |
10/12/2021
| Implemented |
| 6400.193(b)(2) | At the time of the inspection, individual #1 had a hospital bed in her room with bed rails. Although the individual does not need a restrictive plan, because she would be unable to exit the bed with or without the use of the bedrails, the provider was unable to provide documentation that other less restrictive measures were attempted and failed prior to the use of the bedrails and there was also no documentation of a Dr. Orders stating that the bedrails were deemed "medically necessary" for individual #1's health and safety. | For each incident requiring restrictive procedures: A restrictive procedure may not be used unless less restrictive techniques and resources appropriate to the behavior have been tried but have failed. | A call to the PCP was made and a prescription was given for the bedrails and chest plates to ensure the individuals safety. |
10/12/2021
| Implemented |