| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.53(a) | A bottle of nail polish remover was in an unlocked cabinet (Back room "Elm"). It stated to seek medical assistance & contact poison control if ingested. | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | The bottle of nail polish remover was placed in a locked closet at the time of inspection. Direct care staff were reminded of the importance of keeping poisonous materials locked at a meeting on 09.07.2017. The Direct Care workers are responsible for ensuring poisonous materials are locked and the Program Supervisor and Coordinator are responsible for monitoring this. |
09/06/2017
| Implemented |
| 2380.111(c)(7) | This section was not on the physical exam for Individual #1 dated 11/17/2016. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | The physical form for this individual was from a residential provider other than Martha Lloyd. The CEO of the organizations was made aware and an e-mail was sent to the ID Director of the organization requesting that the information be added to their form or a Martha Lloyd Physical form also be completed by the physician at the time of their annual physical.
A checklist has been completed and all physical forms will be reviewed by the Program Specialist to ensure it is complete. There will also be random quarterly checks of physical forms completed by the Program Supervisor to check for accurate information. The Program Specislit is responsible for ensuring the physical is complete and contains the necessary information. |
09/22/2017
| Implemented |
| 2380.173(1)(ii) | Hair color, eye color and identifying marks were not listed in the record for Individual #1. Identifying marks were not listed in the record for Individual #2. | Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks. | The information regarding hair color, eye color and identifying marks have been added to the Information Personal Information document for Individual #1. Identifying marks information has been added for Individual #2. All Individual records have been reviewed by the Program Specialists to ensure all personal information required is included on the document and there are no blank spaces. Program Supervisors will complete a random review of Individual Personal Information documents to ensure information is complete. The Program Specialist is responsible for keeping the information current. |
09/22/2017
| Implemented |
| 2380.173(1)(iv) | Religious affiliation was not listed in the record for Individual #1. Repeat violation: 8/16/2016 | Each individual¿s record must include the following information: Personal information including: Religious affiliation. | The religious affiliation has been added to the Information Personal Information document for Individual #1. All Individual records have been reviewed by the Program Specialists to ensure all personal information required is included on the document and there are no blank spaces. Program Supervisors will complete a random review of Individual Personal Information documents to ensure information is complete. The Program Specialist is responsible for keeping the information current. |
09/22/2017
| Implemented |
| 2380.186(b) | Individual #1 did not sign his ISP Reviews on 10/11/2016 and 7/14/2017. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | The ISP reviews have been signed by Individual #1. The Program Specialists have reviewed all ISP reviews to ensure they have been signed. They have been reminded of the importance of completing this task. The Program Specialist is responsible for ensuring the ISP review is signed. |
09/22/2017
| Implemented |