| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.73(a) | The stairs exiting the basement to the outside do not have a handrail. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | HHOS residential manager has hired a contractor to install a railing on the staircase existing the basement of the home. |
04/12/2021
| Implemented |
| 6400.141(c)(3) | The physical completed for Individual #2 on 9/17/2020 did not include the individual's immunizations. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | The staff will be retrained by the program director on proper documentation for all medical appointments. The training will include will emphasize that all areas of medical forms are completed by the appropriate person. The staff will review each medical form to ensure it included immunization records and it has been completed thoroughly and there are no areas that are left blank or incomplete. |
03/01/2021
| Implemented |
| 6400.141(c)(13) | The physical completed for Individual #2 on 9/17/2020 did not include the Individual's allergies. | The physical examination shall include: Allergies or contraindicated medications. | The staff will be retrained by the program director on proper documentation for all medical appointments. The training will include will emphasize that all areas of medical forms are completed by the appropriate person. The staff will review each medical form to ensure it included allergies (even if there are none) and it has been completed thoroughly and there are no areas that are left blank or incomplete. |
03/01/2021
| Implemented |
| 6400.142(a) | Individual #2 has not seen a dentist since moving into the home on 7/1/09. While the individual refused in 2009, no visits or attempts have been made since then. | 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. | As part of our existing desensitization plan the program specialist will report attempts to complete the necessary dental examinations annually unless otherwise stated in writing by the Dentist. The attempts will be documented on the dental exam form along with reports on the Desensitization plan directly. |
04/07/2021
| Implemented |
| 6400.144 | Individual #2 does have a desensitization/refusal plan in her file, however there is no documentation that attempts were made to schedule dental or gynecologist appointments. There is also no documentation that the plan was utilized in educated the individual on the importance of attending above appointments. | 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.
| As part of our existing desensitization plan the program specialist will report attempts to complete the necessary gynecological examinations annually unless otherwise stated in writing by the Gynecologist. The attempts will be documented on the GYN exam form along with reports on the Desensitization plan directly. |
04/07/2021
| Implemented |
| 6400.34(a) | Individual # 1 and Individual # 2 signed their annual rights on 12-28-20 however, the individual rights have not been updated to reflect changes to the 6100 regulations. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | The annual resident rights have been updated appropriately by the Director. All individuals have signed the revised Resident Rights that reflect the 6100 regulations. The outdated Resident Rights has been removed from the file system. |
02/15/2021
| Implemented |
| 6400.165(g) | Individual #2 had documentation in her file with the "reason for visit" written as "psych med review" on the form on 7/6/2020, 9/17/2020, and 12/15/2020. There is no patient name written on the form for 9/17/2020 and no further verification that the appointment was for Individual #2. On 12/15/2020 the documentation provided is not for a psychotropic medication review, but for a follow up visit to treat the individual's asthma. | 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. | The staff will be retrained by the program director on proper documentation for all medical appointments. The staff will review each medical form to ensure it includes the intended purpose of the visit along with any other documentation and treatment provided by the physician or psychiatrist. |
03/01/2021
| Implemented |
| 6400.166(a)(11) | There is no diagnosis listed for medications on the MARS for Individual #1 or Individual #2. | 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. | The Medication logs have been updated by the Medication Trainer to include the medical diagnosis related to each medication. The staff will be retrained by the medication trainers to include the diagnosis on each MAR they are completing. |
03/01/2021
| Implemented |
| 6400.181(f) | Individual #1's assessment was completed on 10/4/20, his ARU date is 1/15/21, no documentation was provided that the assessment was sent to his team prior to his annual ISP meeting. Individual #2's assessment was completed on 8/1/20, her ARU is 11/1/20, no documentation was provided that the assessment was sent to her team prior to her annual ISP meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | As part of the ISP implementation processes the program specialist will save a copy of the emailed invitation to the ISP team members including attached Assessment 30 days prior to the ISP meeting. The saved email receipt will be kept in the individual¿s file. |
03/01/2021
| Implemented |