| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(c) | A written fire drill record shall be kept of the exit route used. The fire drill record conducted on 10-10-22 did not include the exit route used as this section of the form was left blank. | 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. | UCCH provider reviewed the fire drill forms, the exit route was not documented. The residential supervisor shall make sure all fire drills forms are completed thoroughly. The exit route shall be documented on all fire drill forms completed per regulation 6400.112(c). |
02/06/2023
| Implemented |
| 6400.112(g) | The fire drill conducted during sleeping hours occurred on 3/6/22 at 4:15 am, and the next one occurred on 9/6/22 at 4:15 am. Fire drills shall be held on different times of the day and night. | Fire drills shall be held on different days of the week and at different times of the day and night. | UCCH provider reviewed the fire drill forms, both overnight fire drills were completed at the same time. The residential supervisor must compare all forms to make sure all fire drills be completed on different days and times. The days and times shall be rotated. |
02/06/2023
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medication to treat symptoms of a psychiatric illness. There shall be a review by a licensed physician at least every 3 months, and Individual #1 had psychiatric medication review on 7/22/22 and their next one occurred on 11/8/22. This exceeds the 3 month requirement. Individual #1 had psychiatric medication reviews on 7/22/22 and 4/1/22 and the form used for both visits did not document the medication and necessary dosage of the medication prescribed. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Individual psychiatric appointment was rescheduled to 11/8/2022 due to the doctor being out of the office. Once this happens, the residential supervisor will contact the psychiatrist's office to reschedule with another psychiatrist in order to remain complaint. Should in case an appointment cannot be gotten with another psychiatrist, residential supervisor or the program specialist shall call the PCP and schedule a medication review until the individual's psychiatrist becomes available.
The house supervisors and program specialist have been trained by the CEO on the thorough completion of all medical visit forms. The program director with keep track of all completed psychiatric medical review forms. |
02/06/2023
| Implemented |
| 6400.166(a)(2) | Individual #1's January 2023 Medication Administration Record (MAR) did not include the following prescribers for medications that were administered: Dr. Loghmani, Dr. Sotomango, Dr. Bentziger, Dr. Liaw, Dr. Brown, Dr. Singh, and Benzonatat. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | The individual's medication administration record (MAR) has only one physician's (PCP) name. The CEO corrected and instructed the house supervisors to write out the prescriber of each medication on the MAR immediately. The pharmacy was called by the program specialist, and corrections were made on all individuals' Medication administration record to reflect all prescribers for each medication printed on the MAR for the rest of the months. |
01/25/2023
| Implemented |