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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | The outdoor light to the back deck area did not function during review. | 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 04/01/2023. |
05/01/2023
| Implemented |
| 6400.67(a) | The left window in the living room near the red couch was damaged, the glass was missing from the main window section. The tan couch in the living room was torn on the middle cushion. | 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 the furniture to ensure 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 blinds. The owner will purchase the furniture have them installed 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 the furniture blinds in the homes are presented 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 the furniture 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 to the furniture being in good repair. |
05/01/2023
| Implemented |
| 6400.142(a) | Individual#1 doesn't have a dental record in their record.. There is documentation of correspondence having occurred with special smiles on 2/9/23 where they requested paperwork to be completed.
However, the individual had been a resident for 8 months by this time and greater than 1 month has elapsed since the last documented contact. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Plan to fix the immediate problem: Compliance manager will make sure individuals are getting proper health services. Especially when it comes to including the following items; annually dental due to the need for sedation, 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 individuals are getting proper health services. Especially when it comes to including the following items, annually dental due to the need for sedation, 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 are getting proper health services, especially annually dental due to the need for sedation.
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 individuals are getting proper health services.
- Some Health services weren¿t identified at time of inspections.
- 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 individuals are getting proper health services, by 06/01/2023. |
05/01/2023
| Implemented |
| 6400.144 | Medication Divelproex, 8 125mg capsules to be taken in the evening, prescribed to individual#1 was separated into two separate blister packs with different times. One bubble pack containing 4 capsules said evening and the other said bedtime. The Medication record said all 8 capsules were to be taken together before midnight. The blister packs did completely match 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.
| Plan to fix the immediate problem: Compliance manager will make sure individuals are getting proper health services. Especially when it comes to including the following items; The blister packs so it can completely match the record, 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 individuals are getting proper health services. Especially when it comes to including the following items, The blister packs so it can completely match the record, 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 are getting proper health services, when it comes having the pharmacy redo The blister packs so it can completely match the record.
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 individuals are getting proper health services and have the pharmacy redo The blister packs so it can completely match the record.
- Mediation was split into evening and bedtime blister pack but was given all at bedtime.
- 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 individuals are getting proper health services, by 04/01/2023. |
05/01/2023
| Implemented |
| 6400.181(e)(13)(vii) | The annual assessment for individual#1 dated 9/2/22 does not include information on financial independence or ability to manage personal property. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| Plan to fix the immediate problem: Program specialist will review all individuals¿ assessment to make sure that progress and growth in the area of Financial independence.
Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Program specialist will review all individuals¿ assessment to make sure that they were written progress and growth in the area of functional strengths, needs and preferences of the individual, in current assessments and make sure all progress and growth in the area of Financial independence.
What will be corrected: Program specialist will create a spreadsheet with all individuals¿ assessment date and assessment due date you ensure that the assessment is written and to make sure all upcoming assessments have progress and growth in the area of Financial independence.
When and How: program specialist will review the components of the 6400 and how it should be applied to the areas of non-compliance Program specialist will create a spreadsheet that will be used to verify that assessment has progress and growth in the area of financial independence.
-Program specialist will create expanded progress and growth section by adding information in regard to financial independence.
`Program specialist will create a spreadsheet with all individuals¿ assessment date and assessment due date, by 05/01/2023 |
05/01/2023
| Implemented |
| 6400.24 | There was no record kept of residency prior to employment, no FBI criminal background check completed. The document provided is not a self-attestation for staff member #1. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | Plan to fix the immediate problem: Trainer will review all staff files and to ensure all staff have proper documentation such as FBI Clearance if living or have lived out of the state in the last 2 years upon hire and as needed in accordance to the 6400 regulations.
Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Trainer will review all staff files and to ensure all staff have proper documentation such as FBI Clearance if living or have lived out of the state in the last 2 years upon hire and as needed to the 6400 regulations, that entitles employees ability to serves the individuals.
What will be corrected: Trainer will review all staff files and to ensure all staff have proper documentation such as FBI Clearance if living or have lived out of the state in the last 2 years upon hire and as needed.
When and How: Trainer will review the components of the 6400 and how it should be applied to the areas of non-compliance. Trainer will review all staff files and to ensure all staff have proper documentation that such as FBI Clearance if living or have lived out of the state in the last 2 years upon hire and as needed
- No Documentation such as FBI Clearance if living or have lived out of the state in the last 2 years upon hire and as needed
- Trainer will review all staff files and to ensure all staff have proper that such as FBI Clearance if living or have lived out of the state in the last 2 years upon hire and as needed in accordance to the 6400 regulation, by 06/01/2023. |
05/01/2023
| Implemented |
| 6400.32(r) | Individual#1's bedroom door did not lock. The plans and assessments provided concerning Individual#1, did not discuss whether the individual wanted to be able to lock their bedroom door for privacy. | An individual has the right to lock the individual's bedroom door. | Plan to fix the immediate problem: Compliance Manager will work with house staff and upper management team to establish the best strategy to ensure An individual has the right of privacy, to assure safety and to avoid any violations of rights. We will work with support coordinator to update ISP to discuss the inability of safety when dangerous occurs with locked door.
Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Compliance Manager will work with house staff and upper management team to establish the best strategy to ensure An individual has the right of privacy, to assure safety and to avoid any violations of rights. Compliance Manager will work with the support coordinator and behavior specialist to advise a plan to maintain possessions outside of direct possession, in order to accommodate avoiding rights violate and decreasing behaviors.
What will be corrected: Compliance Manager will work with house staff and upper management team to establish the best strategy to An individual has the right of privacy.
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. Compliance Manager will work with house staff and upper management team to establish the best strategy to ensure An individual has the right of privacy, to assure safety and to avoid any violations of rights. Compliance Manager will work with the support coordinator and behavior specialist to advise a plan to maintain possessions outside of direct possession, in order to accommodate avoiding rights violate and decreasing behaviors.
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- Compliance Manager will work with house staff and upper management team to establish the best strategy to An individual has the right of privacy, to assure safety and to avoid any violations of rights. Compliance Manager will work with the support coordinator and behavior specialist to advise a plan to maintain possessions outside of direct possession, in order to accommodate avoiding rights violate and decreasing behaviors. |
05/01/2023
| Implemented |
| 6400.50(a) | There was no record kept of the orientation training source for staff member #1. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | There was no record kept of the orientation training source for staff member #1.
Plan to fix the immediate problem: Trainer will review all staff files and retrain all staff that don¿t show documentation for orientation, training, including dates held and staff attendance.
Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Trainer will review staff files and retrain all staff that doesn¿t show documentation to show orientation, training, and staff attendance.
What will be corrected: Documentation practices to show the records of how the staff is trained
When and How: C.E.O will review the components of the 6400 and how it should be applied to the areas of non-compliance. Trainer will be retraining all staff that the documentation practices that do show the records of how the staff were being trained
- Documentation practices
- Trainer will be retraining all staff that the documentation practices that do show the records of how the staff were being trained, by 05/01/2023 |
05/01/2023
| Implemented |
| 6400.165(g) | There is no documentation that individual#1has received 3-month medication reviews for the psychiatric medications. | 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. | 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.
Plan to fix the immediate problem: Compliance manager will make sure psychiatrist properly filled out 90-day review form, along with his own typed up documentation. Especially when it comes to including the following treatment symptoms of a psychiatric illness and the reason for prescribing the medication, the need to continue the medication and the necessary dosage, 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 psychiatrist properly filled out 90-day review form, along with his own typed up documentation. Especially when it comes to including the following treatment symptoms of a psychiatric illness and the reason for prescribing the medication, the need to continue the medication and the necessary dosage, 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 psychiatrist properly filled out 90-day review form, along with his own typed up documentation. Especially when it comes to including the following treatment symptoms of a psychiatric illness and the reason for prescribing the medication, the need to continue the medication and the necessary dosage, in accordance to the 6400 regulations, to ensure the individual is receiving the best care that could be provided
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 psychiatrist properly filled out 90-day review form, along with his own typed up documentation.
- psychiatrist properly filled out 90-day review form, along with his own typed up documentation.
- 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 psychiatrist properly filled out 90-day review form, along with his own typed up documentation, by 05/01/2023. |
05/01/2023
| Implemented |
| 6400.213(1)(i) | The face sheet for individual#1 did not include the following:
-Identifying Marks
- Race
- Height
- Weight
- Eye Color
- Religious affiliation
- Primary Language | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Plan to fix the immediate problem: Program specialist will go to all the sites and would review the individuals records to ensure that all intake paper, and face sheet is filled out correctly.
Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Program specialist will go to all the sites and would review the individuals records to ensure that all intake paper and face sheet is filled out correctly, after each new intake. Any current residence who have missing information will have the information put in and dated for the date the noncompliance was discovered.
What will be corrected: Individual¿s record did not have all components on their face sheet.
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 site after new intakes are admitted to ensure all paper has been filled out correctly.
- Program specialist will walk through the site after new intakes are admitted to ensure all paper has been filled out correctly.
- 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 site after new intakes are admitted to ensure all paper has been filled out correctly, by 04/30/2023 |
05/01/2023
| Implemented |
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