| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.66 | The exterior light at the outside doorway at the side of the home is inoperable. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes, that are used by individuals shall be lighted to assure safety and to avoid accidents. | LSP had exterior light installed outside of the doorway at the side of the home on 3/29/23. (Photo sent) |
03/29/2023
| Implemented |
| 6500.74 | The exterior stairs leading to the front porch of the home did not have a nonskid surface. The interior basement stairs of the home did not have a nonskid surface. | Interior stairs and outside steps that are accessible to individuals shall have a nonskid surface. | LSP installed non-skid strips to the basement stairs on 3/29/23 and on the porch stairs on 3/30/23.(Photos sent). |
03/29/2023
| Implemented |
| 6500.183 | Individual #1's most current record information was not kept at the family living home. | Copies of the most current record information required in §6500.182(c)(1)¿(14) (relating to individual records) shall be kept in the family living home. | The Specialist compiled a binder for each person receiving Life Sharing Supports that contains current copies of their information as required by the regulations. This will be presented to the LSP and will be reviewed that it is current and being kept in the home on each monthly home visit. This has occurred for this home on 3/30/23. |
03/30/2023
| Implemented |
| 6500.136(a)(7) | The medication label for Risperidone 1MG/ML solution prescribed to Individual #1 reads, "take 0.5ML (0.5mg) in the morning and 1ML (1mg) in the evening daily via feeding tube. Individual #1's March 2023 Medication Administration Record reads, "take 0.5ML (0.5mg) in the morning and 1.5ML (1.5mg) in the evening a day via feeding tube." | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | Achieva¿s Clinical Team Nurse corresponded with Dr. Taylor, Dr. Uribe (PCP) and CVS Pharmacist beginning on 3/17/23 to ascertain how the discrepancy between the Risperdone label and the MAR occurred. Dr. Taylor is the prescribing physician and did not change the order. It was discovered that the PCP sent orders to CVS for the Rispersdone unbeknownst to Achieva or Dr. Taylor. It was confirmed with the PCP that [Individual #1] is taking the correct dosage of Risperdone as stated on the MAR, which is the dosage prescribed by Dr. Taylor since 9/16/21. The PCP agreed to discontinue their oder. This is what was required by CVS to make the label change to correctly reflect the prescribed dosage of 1.5mg of Risperdone. The MAR and label are both correct as of 4/3/23. (Photos of Label, MAR, and Clinical team documentation have been sent.) |
04/03/2023
| Implemented |