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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | There is a large, unlocked walk-in closet on the second floor of the residence, in Individual 1's bedroom. Staff on site and Individual #1 indicated that they did not know what was behind the door. Upon inspection, the closet did not have any windows, lighting fixtures, or other light sources---it was pitch black during daytime hours to the point that a flashlight was required to see within the room. These lighting conditions are unsafe. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Plan to fix the immediate problem: Compliance Manager will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Compliance will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, , especially when it comes Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
What will be corrected: Make sure are sites are on clean and sanitary conditions, especially when it comes to having proper lighting.
When and How: Compliance Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance and will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, comes to , especially when it comes Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
- Compliance Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
- Compliance manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly, and to make sure are sites are on clean and sanitary conditions, , especially when it comes Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents, by 04/01/2021. |
04/01/2021
| Implemented |
| 6400.67(a) | There is a large, unlocked walk-in closet on the second floor of the residence, in Individual #1's bedroom. There was a worn and tattered carpet on the floor, large amounts of dust on all surfaces, and assorted trash on the floor, including an empty box of Cheese-It crackers. | Floors, walls, ceilings and other surfaces shall be in good repair. | Plan to fix the immediate problem: House manager will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to all areas of the home being in good repair, to ensure that home is being kept in good repair.
Who (job title) will be responsible for correcting the problem (each step in the process) in the future: House Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to keeping all areas in the home in good repair. The owner will the maintenance man make the repairs, to ensure the home is in good standing.
What will be corrected: Make sure are sites are on clean and sanitary conditions, especially when it comes to all areas of the home being in good repair, to ensure that home is being in good repair.
When and How: House Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance and will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to all areas of the home being in good repair, to ensure that home is being in good repair.
- House Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes areas in the home being clean, to ensure that home is being in good repair.
- House manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly, and to make sure are sites are on clean and sanitary conditions, especially when it comes areas in good repair, by 04/01/2021 |
04/01/2021
| Implemented |
| 6400.80(b) | There was a roughly 6-foot segment of picket fence, which staff on site reported was from an adjoining neighbor's fence, strewn in the back yard of the home, posing a potential hazard. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | Plan to fix the immediate problem: Compliance Manager will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings, as well outdoor areas to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the yard being kept, to assure safety and to avoid accidents.
Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Compliance will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings as well outdoor areas, to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the yard being kept, to assure safety and to avoid accidents.
What will be corrected: Make sure are sites are on clean and sanitary conditions, especially when it comes to the yard being kept, to assure safety and to avoid accidents.
When and How: Compliance Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance and will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings, as well outdoor areas to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the yard being kept and free of items, to assure safety and to avoid accidents.
- Compliance Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings, as well outdoor areas to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the yard being kept, to assure safety and to avoid accidents.
- Compliance manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings, as well outdoor areas, to ensure they are in good repair. The broke items will be removed or replaced correctly, and to make sure are sites are on clean and sanitary conditions, especially when it comes to yards being kept, to assure safety and to avoid accidents, As of 04/01/2021. |
04/01/2021
| Implemented |
| 6400.82(f) | There was no trash can in the first floor bathroom. | 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. | Plan to fix the immediate problem: Compliance Manager will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings, as well outdoor areas to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes trash cans in the bathrooms, to assure safety and proper disposal.
Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Compliance will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings as well outdoor areas, to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes trash cans in the bathrooms, to assure safety and proper disposal.
What will be corrected: Make sure are sites are on clean and sanitary conditions especially when it comes trash cans in the bathrooms, to assure safety and proper disposal.
When and How: Compliance Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance and will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings, as well outdoor areas to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes trash cans in the bathrooms, to assure safety and proper disposal.
- Compliance Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings, as well outdoor areas to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes trash cans in the bathrooms, to assure safety and proper disposal.
- Compliance manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings, as well outdoor areas, to ensure they are in good repair. The broke items will be removed or replaced correctly, and to make sure are sites are on clean and sanitary conditions, especially when it comes trash cans in the bathrooms, to assure safety and proper disposal, As of 04/01/2021. |
04/01/2021
| Implemented |
| 6400.112(e) | There was no sleep drill held between February 2020 through July 2020. | A fire drill shall be held during sleeping hours at least every 6 months. | Plan to fix the immediate problem: Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period.
Who (job title) will be responsible for correcting the problem (each step in the process) in the future Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period, monthly.
What will be corrected: Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period.
When and How: Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance. Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period.
- Program specialist will walk through the sites monthly to ensure fire drills are conducted in accordance to the 6400 regulations. Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period.
- Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance: Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period, by 05/01/2021 |
05/01/2021
| Implemented |
| 6400.141(c)(9) | Individual #1 turned 40 on 10/25/19 and has not yet had a prostate exam. | The physical examination shall include: A prostate examination for men 40 years of age or older. | Plan to fix the immediate problem: Compliance manager will make sure primary doctors have properly filled out physical form. Especially when it comes to including the following items: Prostate exam, in accordance to the 6400 regulations.
Who (job title) will be responsible for correcting the problem (each step in the process) in the future: compliance manager will make sure primary doctors have properly filled out physical form. Especially when it comes to including the following items, Prostate exam, in accordance to the 6400 regulations. original signature only and not electronically sign individual physical form in accordance to the 6400 regulations, to ensure the individual is receiving the best care that could be provided.
What will be corrected: That all participants primary care physical properly fill out annual physical forms.
When and How: Compliance manager will review the components of the 6400 and how it should be applied to the areas of non-compliance. Compliance manager will review all individual¿s files and to ensure all individual¿s primary care physical properly fill out annual physical forms.
- primary doctor did not complete all areas of the annual physical form.
- Compliance manager will review the components of the 6400 and how it should be applied to the areas of non-compliance. Compliance manager will review all individual¿s files and to ensure all individual¿s primary care physical properly fill out annual physical forms, by 06/01/2021. |
06/01/2021
| Implemented |
| 6400.165(e) | Individual #1 Med Review] Staff on site failed to locate the medication Fluticasone Inhaler Salmeter, which was documented as a current medication on the February 2021 and March 2021 Medication Administration Records (MAR) for Individual #1, during the inspection's medication review. Upon subsequent investigation, staff uncovered that the medication had been discontinued by the medical provider effective 02/04/2021; however, this information had not been updated on the MAR. Residential staff continued to initial for administration despite discontinuation. | Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received. | Plan to fix the immediate problem: Staff will make sure all individuals have medication logs that match the labels after doctor visit.
Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Staff will call the individuals doctors, if needed to ensure doses are correct if no medication changes were made, while at the doctor visit, while adhering to 6400 regulations.
What will be corrected: Staff will call the individuals doctors, if needed to ensure doses are correct if no medication changes were made, while at the doctor visit.
When and How: Staff will review the components of the 6400 and how it should be applied to the areas of non-compliance. Program specialist will be retraining all staff on individual service plans, focusing on calling the individuals doctors, if needed to ensure doses are correct if no medication changes were made, while at the doctor visit.
- Medication logs had a medication that didn¿t match the labels after doctor visit.
- Program specialist will be retraining all staff on individual service plans, focusing on calling the individuals doctors, if needed to ensure doses are correct if no medication changes were made, while at the doctor visit, by 03/09/2021. |
03/09/2021
| Implemented |
| 6400.166(a)(2) | Each medication on Individual #1's MAR from February 2021 lacked the prescribing physician's name associated with that medication. Medications affected include: Diltiazem 240mg ER, Fluticasone Inhaler Salmeter, Montelukast 10mg, and Albuterol Sulfate HFA 90mcg. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | Plan to fix the immediate problem: Manager will make sure all individuals have medication logs that match the labels, including prescribers name.
Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Manager will call the individuals pharmacist to make sure providers name is added to medication log, while adhering to 6400 regulations.
What will be corrected: Manager will call the individuals doctors, if needed to ensure doses are correct if no medication changes were made, while at the doctor visit.
When and How: Manager will review the components of the 6400 and how it should be applied to the areas of non-compliance. Program specialist will be retraining all staff on individual service plans, focusing on calling the Pharmacist, if needed to ensure doses are correct if no medication changes were made, including prescribing doctor.
- Medication logs had a medication that did not included prescribers name.
- Program specialist will be retraining all staff on individual service plans, focusing on calling the house manager, if needed to ensure prescribers name is listed on medication log, while at the doctor visit, by 03/09/2021. |
03/09/2021
| Implemented |
| 6400.166(a)(4) | A Symbicort Inhaler was located during the review of Individual #1 medications; however, there was no record of this medication found within the February 2021 or March 2021 Medication Administration Records (MAR). A prescription was provided to show that Individual #1 was prescribed this medication effective 02/05/2021. The name of each medication prescribed must be documented within the individual #1's MAR | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | Plan to fix the immediate problem: Manager will make sure all individuals have medication logs that match the labels, and new medications are added to medication log.
Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Manager will call the individuals pharmacist to make sure medications are added to medication log, while adhering to 6400 regulations.
What will be corrected: Manager will call the individuals doctors, if needed to ensure doses are correct if no medication changes were made and calling individuals pharmacist to make sure medications are added to medication log.
When and How: Manager will review the components of the 6400 and how it should be applied to the areas of non-compliance. Program specialist will be retraining all staff on individual service plans, focusing on calling individuals pharmacist to make sure medications are added to medication log.
- Medication logs had a medication that did not appear on it.
- Program specialist will be retraining all staff on individual service plans, focusing on calling the house manager, if needed to ensure individuals pharmacist to add to medication log, by 03/09/2021. |
03/09/2021
| Implemented |
| 6400.166(a)(13) | Individual #1's February 2021 Medication Administration Record (MAR) contains several unclear initials for administration. These include entries for Fluticasone Inhaler Salmeter on 02/17/2021 at 7:00am and 02/18/2021 at 7:00am, as well as an entry for Diltiazem 240mg ER on 02/11/2021 at 7:00am. In each case, the corresponding initials are either scribbled or crossed out, rendering them illegible. Due to this, it cannot be determined which staff administered these medications at these times. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | Plan to fix the immediate problem: Manager will make sure all individuals have medication logs that displays visible signatures.
Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Manager give out write ups to any staff unable to comply with legible initials, while adhering to 6400 regulations.
What will be corrected: Manager will make sure all individuals have medication logs that displays visible signatures.
When and How: Manager will review the components of the 6400 and how it should be applied to the areas of non-compliance. Program specialist will be retraining all staff on individual service plans, focusing on making sure all individuals have medication logs that displays visible signatures.
- Medication logs had an initials that did not appear on legible.
- Program specialist will be retraining all staff on individual service plans, focusing on calling the house manager, if needed to ensure all individuals have medication logs that displays visible signatures, by 03/09/2021. |
03/09/2021
| Implemented |
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