| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.67 | The light switch near the door frame of Individual #4's bedroom was contained in an electrical box that was not recessed into the wall and not properly secured to the wall creating a safety hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The electrical box was tightened. |
03/24/2023
| Implemented |
| 6500.101 | An exterior exit door was located in the bedroom of Individual #4. A dresser was partially in front of the exit door preventing it from opening fully and obstructing egress from the room. Exits from the home shall be unobstructed. | Stairways, halls, doorways and exits from rooms and from the home shall be unobstructed. | The dresser was moved so it is not preventing the exit door from being fully opened. |
04/03/2023
| Implemented |
| 6500.151(e)(4) | The "Supervision Care Needs" section of the Individual Support Plan (ISP) for Individual #4 last updated on 11/14/22 indicates that "has no unsupervised time in the community when with Martha Lloyd services. is able to stay in "their" life sharing provider's car for up to 5 minutes while she runs into a store/gas station." Individual #4 is not properly identified by name or gender in the assessment. The assessment for Individual #4 dated 2/27/23 indicates that "Community Supervision: Is able to be without direct staff supervision for: 5 minutes. Explanation: (Incorrect Name) is within hearing range most of the time at home. She can sit quietly by herself but her provider assists her with stability while walking. She can have 5 minutes of community unsupervised time if she is sitting by herself." The assessment does not include the correct level of supervision for Individual #4. | The assessment must include the following information: The individual's need for supervision. | The assessment was revised to include the correct name and the correct supervision level. |
03/23/2023
| Implemented |
| 6500.34(a) | Individual #3 was informed of their rights on 1/2/23. The rights reviewed haven't been updated to reflect the current Chapter 6500 regulations. The missing right is that the primary caregiver shall have the key or entry device to lock and unlock the door. Individual #4 was informed of their rights on 1/2/23. The rights reviewed haven't been updated to reflect the current Chapter 6500 regulations. The missing right is that the primary caregiver shall have the key or entry device to lock and unlock the door. | Individual rights and the process to report a rights violation shall be explained to the individual, and persons designated by the individual prior to moving into the home and annually thereafter. | Individual rights were revised to include that the primary caregiver shall have a key or entry device to lock and unlock the door. |
03/24/2023
| Implemented |
| 6500.135(c) | Individual #4 is prescribed Apple Cider Vinegar tablets due to a diagnosis of Acid Reflux. Pharmacy label directions state "Give 1-2 tablets daily at 8am." The manufacturer label directions state "As a dietary supplement, adults take one(1) tablet after any meal or as directed by a healthcare provider. Do not exceed recommended dosage." The March 2023 Medication Administration Record (MAR) for Individual #4 records an entry for "Apple Cider Vinegar, 1000mg, 2tabs." Staff #3 initials indicate that 2 tablets of the medication have been administered each day at 8am. Further clarification that 2 tablets of the medication should be given daily instead of the 1-2 tablets daily as directed on the Pharmacy label was not provided. It could not be determined that the medication was being administered as prescribed due to the discrepancies between the MAR and Pharmacy label directions. | A prescription medication shall be administered as prescribed. | Providers were reminded that the medication label and log need to match word for word. Program Specialist both took the modified ODP medication course so that they know what is required. MAR's are also being typed so there is less room for error. |
04/11/2023
| Implemented |
| 6500.136(a)(9) | The March 2023 Medication Administration Record (MAR) for Individual #3 did not include the frequency of administration for the medications entered. Entries on the MAR were as follows: "Digestive Enzymes, 1 capsule," "Apple Cider Vinegar, 1000mg, 2 tabs," and "Calcium, Magnesium & Zinc Combo, 1 tab." The frequency of administration should be recorded on the MAR. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | Providers were reminded that the medication label and log need to match word for word. Program Specialist both took the modified ODP medication course so that they know what is required. MAR's are also being typed so there is less room for error. |
03/22/2023
| Implemented |
| 6500.151(a) | The Assessment for Individual #4 refers to the individual as the incorrect name and gender. The Assessment for Individual #4 dated 2/27/23 contained the following statements: "Her provider buckles and unbuckles her." "Is cooperative for her FLP and certain other people she knows well." and "(Incorrect Name)is within hearing range most of the time at home. She can sit quietly by herself but her provider assists her with stability while walking. She can have 5 minutes of community unsupervised time if she is sitting by herself." The assessment for Individual #4 dated 3/7/22 contains the same incorrect language of "(Incorrect Name) is within hearing range most of the time at home. She can sit quietly by herself but her provider assists her with stability while walking. She can have 5 minutes of community unsupervised time if she is sitting by herself." and "Her provider buckles and unbuckles her." .
Assessments that lack quality i.e., are not individualized, personalized, relevant to the person's age and do not address the specific needs of the person, will lead to services that lack quality; services that lack quality lead to harm. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the home. | The assessment was revised to include the correct name. All plans will include the correct name. |
03/23/2023
| Implemented |