| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | Repeat from Inspection dated 5/10/21- Individual #1's Snap Benefits are being used for the entire household and not just to benefit the individual. There was no consent form in the record, documenting Individual #1 consented to allowing their Snap Benefits to be used for the entire house. | Individual funds and property shall be used for the individual's benefit. | Staff for all supported individuals through the OADOS are given 30 days to get documents explained and signed by individuals or their guardians. |
11/30/2021
| Implemented |
| 6400.64(a) | Individual #1's bathroom was not clean and sanitary. There was a one-inch smear of fecal matter on the outside of the toilet on the bottom right. Individual #1's bathtub had a layer of black grime on the backside of the tub. There was a layer of dirt on the floor and walls of the bathroom. | Clean and sanitary conditions shall be maintained in the home. | The bathtub and toilet were promptly cleaned on the same day as the violation was noticed. |
01/31/2022
| Implemented |
| 6400.82(f) | Individual #1's bathroom did not have toilet paper available in the bathroom at the time of the inspection on 10/14/21. Individual #2's bathroom did not have paper towels or individual hand towels available at the time of the inspection on 10/14/21. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | This was provided in each of the bathrooms on the same day as the lack of availability was noted. |
01/31/2022
| Implemented |
| 6400.112(a) | There was no record of a successful fire drill being conducted in August 2021 | An unannounced fire drill shall be held at least once a month. | Fire Drill Monitoring and the entry of appropriate post drill information has been reinforced with all Quality Staff to Monitor and with ADOS personnel concerning unoccupied locations. |
11/05/2021
| Implemented |
| 6400.141(a) | Individual #1 had an annual physical on 9/29/20 and not again since; outside of the annual timeframe. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | OADOS and CADOS personnel are rapidly making all necessary appointments as they have been identified. New CADOS and Nursing Personnel have made and kept appointments that were needed in each person's record as identified. |
12/01/2021
| Implemented |
| 6400.143(a) | Individual #1 is to brush their teeth twice a day and floss once a day. From 5/1/21 through 10/13/21, Individual # 1 only flossed 13 times. Individual #1 is to work out 15-20 minutes a day. From 5/1/21 through 10/13/21, only worked out for 15 to 20 minutes a day 27 times. The refusals for flossing and exercising were documented. There was no documentation that education was provided to Individual #1 training on the importance of following doctor's recommendations. Individual #1 refused to take all of their medications on the following dates: 5/29/21, 6/2/21, 6/7/21, 7/31/21, 9/2/21, 9/3/21, 9/12/21, and 9/20/21. There is no documentation that Individual #1 is being educated on the importance of following doctor's recommendations. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | The training of staff on the need to train individuals on the risks of not following medical orders/recommendations has been undertaken by the OADOS and CADOS personnel in these homes. I need to provide you with dates and training logs. |
12/01/2021
| Implemented |
| 6400.144 | Repeat from 5/10/21-
*Individual #1 is not safe around sharp objects. Sharp objects are to be locked in the home. On, 10/14/21, the date of the inspection, the sharp objects were unlocked.
*Individual #1 attended their annual physical on 9/29/20. At that appointment it was recommended that the individual have lab work completed every six months to test their thyroid. The lab work was completed on 11/12/20 and not again since, outside of the six-month time frame.
*Individual #1 had a psychiatry appointment on 7/26/21. At that appointment, it was recommended that a consult be had with the BCBA for review of head tapping and breaches of personal space. It was also recommended that the Functional Behavioral Assessment be re-evaluated. The consultation did not occur with the BCBA. The FBA was completed 12/21/18 and has not been updated since.
*Individual #1 is to have a podiatry appointment every 8 weeks. Individual #1 had a scheduled Podiatry appointment on 8/23/21. Staff forgot to take Individual #1 to the appointment. Individual #1 was a no-show. No follow-up appointment has occurred.
* Individual #1 was hospitalized through 10/7/21. Individual #1 was to follow-up with their Primary Care Physician within 7 days. As of 10/14/21, the Individual had not followed up with their PCP. The follow-up appointment is scheduled for 10/18/21; outside of the 7-day window.
*Individual #1 is prescribed Urea Cream 40% to be administered twice a day. On 10/14/21, no Urea Cream was available in the home. On Individual #1's MAR the Fluticasone was marked as "not scheduled" from 10/14/21. Individual #1 is still prescribed Fluticasone and did not receive it on 10/14/21. | 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.
| Sharps were locked and staff was retrained within 24 hours of the notification of this citation
The OADOS, Director of Operations, Director of Compliance and the BCBA all spoke with the mother and attempted to work with the physician's office to get an earlier appointment.
The OADOS/CADOS are getting standing orders for this lab work for this individual from the PCP. Need to check on status.
The BCBA has contacted appropriate parties and made appointments to do the assessment as required by the physician order.
Urea Cream was obtained and the Quality Coordinator showed the OADOS how to do this and what to say to the pharmacy. We also identified and performed a certified investigation on this particular item and its lack of availability. It was completed and confirmed findings were made by the Admin Review on Friday, October 29, 2021.
The OADOS is scheduling missed and standing appointments with the help of new CADOS personnel |
12/01/2021
| Implemented |
| 6400.52(c)(6) | Repeat from Inspection dated 8/11/21-Staff #1 to Staff #20 were not trained on Individual #1's Health and Safety Plan completed 10/29/20. Staff #1 to Staff #7, Staff #9, Staff #14 to Staff #18, and Staff #20 were not trained on Individual #1's Behavior Support Plan dated 11/1/18. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | A new training methodology with different signed training logs was put in place within 3 days of the licensing inspection by the BCBA, Director of Operations, Director of Services and the ED. |
12/01/2021
| Implemented |
| 6400.165(c) | Repeat from Inspection dated 5/10/21-On 5/24/21, Individual #1 did not receive their Divalproex 500mg at 12pm. Individual #1 did not receive their Risperidone 1mg at noon on 5/25/21. Individual #1 did not receive the following medications on 6/27/21: Benztropine .4mg at 4pm, Divalproex 500mg 4pm, Divalproex 500 mg 8pm, Lamotrigine, Melatonin, Oxybutnin, Risperidone 2mg at 4pm, Tamsulosin, Urea Cream, and Vasoline. Individual #1 did not receive their Urea Cream or Vaseline on 8/26/21. The Individual did not receive Urea Cream on 9/3/21 nor 9/10/21 as prescribed. | A prescription medication shall be administered as prescribed. | Continued retraining in CaraSolva will be performed for all staff. All staff have been retrained/trained (if new) in ODP's Med Admin Training Program. Emphasis on this process continues. |
12/01/2021
| Implemented |
| 6400.166(a)(11) | Repeat from Inspection dated 5/10/21- Individual #1's MAR does not list the diagnosis/purpose for each medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | A software update request with CaraSolva has been requested, also with Foothold (AWARDS), but nothing is imminent. The Nursing Staff has completed this part of their project as of 10/30/21. |
11/15/2021
| Implemented |
| 6400.166(b) | The following medications that were administered, were not logged immediately on 9/25/21 at the 8am dose: Oxybutnin, Risperidone, Vaseline, Vitamin D3, Benztropine, Divalproex, Fluticasone, Lamotrigine, Levothyroxine, and Loratidine. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | A software update request with CaraSolva has been requested, also with Foothold (AWARDS), but nothing is imminent. Late administration does not show as an error. |
12/31/2021
| Implemented |
| 6400.167(a)(1) | Individual #1 did not receive their Urea Cream on 9/23/21, 9/24/21, nor 9/30/21, because the medication tube was empty. On 10/8/21, Individual #1 did not receive the following 8pm meds: Divalproex, Lamotrigine, Melatonin, and Oxybutnin. Individual #1 did not receive their 8am dose of Fluticasone on 10/14/21. Individual #1 did not receive their 8am dose of Levothyroxine on 10/11/21 or 10/12/21. | Medication errors include the following: Failure to administer a medication. | Training on Incident Reporting for the whole agency begins on November 5. The Quality Coordinator and two CIs are auditing medication administration reports for October to identify errors. |
12/01/2021
| Implemented |
| 6400.167(c) | Individual #1 did not receive their Urea Cream on 9/23/21, 9/24/21, nor 9/30/21, because the medication tube was empty. On 10/8/21, Individual #1 did not receive the following 8pm meds: Divalproex, Lamotrigine, Melatonin, and Oxybutnin. Individual #1 did not receive their 8am dose of Fluticasone on 10/14/21. Individual #1 did not receive their 8am dose of Levothyroxine on 10/11/21 or 10/12/21. The medication errors were not reported to EIM. | A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). | Training on Incident Reporting for the whole agency begins on November 5. The Quality Coordinator and two CIs are auditing medication administration reports for October to identify errors. |
12/01/2021
| Implemented |