| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.70 | The home did not have an operable telephone in the home | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| Telephone line was plugged on wrong porter by individual. Royal Home Care contacted Comcast who came on 8/2/2023 to diagnose and reconnected the phone line to the right porter. Telephone is now functional and dialing and receiving calls (see attached). |
08/02/2023
| Implemented |
| 6400.144 | On most recent physical dated 6/29/23 it was indicated that individual 7 needs to follow up with neurology. There is no documentation of a neurology appointment in the record. | 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.
| A neurology appointment was scheduled and completed on 10/19/2023. Going forward, staff will take individual to all appointments (initial and follow-up) to ensure compliance. The Nurse and Program specialist will carryout a routine audit of all completed appointments to ensure that they are done as at when due. Training regarding 6400 compliance was completed with staff, house supervisor, nurse and program specialist on 08/03/2023 |
08/03/2023
| Implemented |
| 6400.32(r) | Individual rights do not reflect that individual 7's right to lock their door. | An individual has the right to lock the individual's bedroom door. | Royal Home Care administrator immediately updated policy containing the rights of the individual to include individuals right to lock their bedrooms (see attached). Individuals' files have been updated 8/01/23 to ensure compliance. |
08/01/2023
| Implemented |
| 6400.165(g) | Psychotropic reviews were not completed every three months for individual 7. Dates completed.
· 10/2022
· January 2023-missins
· April-missing
Next quarterly review was completed 5/23/23.
Psychotropic Quarterly review for January 2023 is not in the record. | 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 completed psychotropic med reviews via telehealth as a result of covid-19 concerns. Going forward, the nurse, the program specialist, and the residential supervisor will ensure that all scheduled psychotropic med reviews are completed accordingly for all individuals. Supporting documents will be filed immediately after the visits in individual¿s medical book. Training regarding 6400 compliance was completed with the house supervisor, the nurse and program specialist on 08/01/2023 |
08/01/2023
| Implemented |
| 6400.183(b) | ISP sign in sheet provided for ISP meeting held August 2022 did not include at least 3 members for individual 7. | At least three members of the individual plan team, in addition to the individual and persons designated by the individual, shall be present at a meeting at which the individual plan is developed or revised. | Individual ISP meeting was completed virtually and had a low attendance due to covid-19 concerns. Going forward, the program specialist will ensure that all ISP meeting meets the attendance requirement of at least 3 members. Attendance sheet and all supporting documents will be filed immediately after the meeting. Training regarding 6400 compliance was completed with program specialist on 08/01/2023 |
08/01/2023
| Implemented |