| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(2) | (Repeated Violation -- 11/28/21) Individual #1 is not financially independent. There is a cash box and wallet where Individual #1's money is kept, both with a ledger. Between May and June 2022, there were incorrect balances on Individual #1's cash box ledger, changing the correct balance amount for the month. | (2) Disbursements made to or for the individual.
| House Managers will be retrained by the Executive Director on the process for completing individual financial logs (wallet and lock boxes) accurately and completely. |
10/31/2022
| Implemented |
| 6400.64(a) | At the time of the 10/4/22 inspection, the fabric on the kitchen chairs was very stained with unknown substances. | Clean and sanitary conditions shall be maintained in the home. | The House Manager will begin the process of shopping for a new dining room set. The House Manager will send options to the Executive Director of Operations for approval to purchase, to ensure it is within the home's budget. The new dining room set will be ordered no later than 11/18/22. |
10/31/2022
| Implemented |
| 6400.67(a) | At the time of the 10/4/22 inspection, the metal electric heat register along the side of and behind the toilet was very rusted. | Floors, walls, ceilings and other surfaces shall be in good repair. | A work order will be completed and sent to the maintenance department for repair by 10/13/2022, by the Executive Director of Operations. The request will be dated for repair to be addressed by 10/31/2022. |
10/31/2022
| Implemented |
| 6400.111(f) | The fire extinguishers at this home were inspected on 12/1/20 and not again until 12/14/21. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | The Executive Director of Operations will meet with the Maintenance Director to review the regulation above to ensure that all fire extinguishers are inspected within 364 days of the previous year's inspection. |
10/31/2022
| Implemented |
| 6400.144 | Individual #1 had a podiatrist appointment on 2/4/22 in which the podiatrist ordered Individual #1's left big toe to be cleaned once daily and Neosporin applied for 5 days. There is no documentation provided verifying that this order was followed.
Individual #1's doctor discontinued their evening dose of pantoprazole on 3/14/22. The morning dose remained unchanged, and the doctor requested contact in 4 weeks regarding this change. There is no documentation provided verifying that the doctor was contacted for this follow-up request. | 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.
| House Manager will contact the PCP to follow up on the medication (pantoprazole) change that was implemented on 3.14.22 to update the PCP on how the change is/is not working. Documentation will be written on the appointment chart.
Staff will be retrained by the Program Specialist on documentation requirements related to all aspects of the individual's care plans to ensure that the individuals are receiving all services to keep them healthy and safe. |
10/31/2022
| Implemented |
| 6400.46(c) | Staff person #2 began working with individuals on 1/17/22. Staff person #2 was not trained in general first aid until 1/19/22.
Staff person #4 began working with individuals on 6/21/22. Staff person #4 was not trained in general first aid before they were CPR and First Aid certified on 8/1/22. | Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home shall be trained before working with individuals in first aid techniques. | The Training Coordinator will schedule all new employees within their first two weeks of employment, to receive the required training. The HR Assistant will notify the Training Coordinator of all new employees in order for the training to be scheduled within the first two weeks of employment. |
10/31/2022
| Implemented |
| 6400.46(d) | Staff person #5 completed a 2-year certification for CPR and First Aid on 8/14/20. This staff person did not complete a recertification until 9/21/22. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | The Training Coordinator will work with J&FC's CPR/First Aid Certified Trainer, to develop an annual CPR/First Aid training spreadsheet of all employees, to ensure training is completed by their biannual due date. |
10/31/2022
| Implemented |
| 6400.51(a)(3) | Staff person #4 began working on 6/3/22. Staff person #4 did not complete the orientation requirements in 6400.51b1 -- 6400.51b5 until 7/18/22. The requirements in 6400.51b1 were not completed until 7/13/22. The requirements in 6400.51b2 and 6400.51b4 were not completed until 7/7/22. The requirements in 6400.51b3 were not completed until 7/18/22. | Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Direct service workers, including full-time and part-time staff persons. | The Training Coordinator will schedule all new employees within their first two weeks of employment, to receive the required training. The HR Assistant will notify the Training Coordinator of all new employees in order for the training to be scheduled within the first two weeks of employment. |
10/31/2022
| Implemented |
| 6400.51(b)(1) | Staff person #2 was hired on 12/30/21. Staff person #2 did not receive training in person centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships until 2/1/22. | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The Training Coordinator will schedule all new employees within their first two weeks of employment, to receive the required training. The HR Assistant will notify the Training Coordinator of all new employees in order for the training to be scheduled within the first two weeks of employment. |
10/31/2022
| Implemented |
| 6400.51(b)(3) | Staff person #2 was hired on 12/30/21. Staff person #2 did not receive training in individual rights until 2/25/22. | The orientation must encompass the following areas: Individual rights. | The Training Coordinator will schedule all new employees within their first two weeks of employment, to receive the required training. The HR Assistant will notify the Training Coordinator of all new employees in order for the training to be scheduled within the first two weeks of employment. |
10/31/2022
| Implemented |
| 6400.165(b) | The October Medication Administration Record for Individual #1 lists Debrox 6.5% ear drops- administer 5 drops into each ear canal twice daily as needed for up to 10 days. The medication at the home that is being administered to Individual #1 is Floxin- Ofloxacin Dro 0.3% instill 5 drops into Right ear twice daily for 7 days. | A prescription order shall be kept current. | House Manager will contact the PCP requesting a current physician order for the Floxin-Ofloxacin drops. |
10/31/2022
| Implemented |
| 6400.166(a)(11) | The following medications on Individual #1's October Medication Administration Record do not include the diagnosis or purpose of the medication: Risperidone, Sodium Fluoride, Acetaminophen, and Olopatadine. | 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. | House Manager will update the October MARs for the following medications - Risperidone, Sodium Fluoride, Acetaminophen and Olopatadine - including the diagnosis or purpose of these four medications. |
10/31/2022
| Implemented |
| 6400.166(b) | The following medications were administered to Individual #1, but the administration was not documented at the time of administration:
· 2/9/22 -- All 8am pill-form medications
· 2/20/22 -- All 8am pill-form medications
· 4/30/22 -- Levothyroxine
· 5/20/22 -- Escitalopram
· 7/11/22 -- Levothyroxine
· 8/15/22 - Escitalopram | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | House Manager and staff will be retrained by J&FC Certified Medication Trainer on the following sections (7 & 8) of the medication administration course to guarantee that all staff understand the expectations in order to stay within compliance of this regulation. |
10/31/2022
| Implemented |
| 6400.167(a)(1) | Individual #1 was not administered the following medications on the dates below:
· 12/26/21 -- levothyroxine
· 12/1/21, 12/2/21, 12/3/21 -- eye scrub
· 2/9/22 -- Metronidazole Cream, Olopatadine drops
· 2/20/22 -- Metronidazole Cream, Olopadatine drops
· 3/11/22 -- Azelastine Spray
· 4/11/22 -- ocusoft eye pads
· 5/9/22 -- Olopatadine drops
· 5/14/22 and 5/15/22-- Ocusoft eye pads
· 5/20/22 -- Azelastine Spray
· 7/25/22 -- Escitalopram
· 8/15/22 -- Metronidazole Cream, Azelastine spray, Olopatadine drops, and Ocusoft eye pads | Medication errors include the following: Failure to administer a medication. | House Manager and staff will be retrained by J&FC Certified Medication Trainer on the following sections (7 & 8) of the medication administration course to guarantee that all staff understand the expectations in order to stay within compliance of this regulation.
House Manager and staff will be retrained by J&FC Trainer on the incident management bulletin specifically medication errors and when it leads to neglect, when it needs to be reported and how it is prevented. |
10/31/2022
| Implemented |
| 6400.167(b) | There is no documentation of the follow up actions taken for the medication errors described in 6400.167a1. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | House Manager and staff will be retrained by J&FC Certified Medication Trainer on proper documentation of medication errors and follow up action that needs to be done.
House Manager will be retrained by J&FC lead certified investigator on proper documentation required for a medication error including follow up actions and responses if applicable. |
10/31/2022
| Implemented |
| 6400.167(c) | The medication errors described in 6400.167a1 were not reported in the department's incident management system. | A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). | House Manager and staff will be retrained by J&FC Trainer on the incident management bulletin specifically medication errors and when it leads to neglect, when it needs to be reported and how it is prevented to guarantee that all staff understand the expectations in order to stay within compliance of this regulation. |
10/31/2022
| Implemented |