| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(2) | Individual #1 receives SNAP benefits, which are managed by the provider agency. The current log in the home ends on 1/9/24. There is no current, up-to-date log as of 3/21/24. | (2) Disbursements made to or for the individual.
| Residential manager and Finance Controller will collect all SNAP receipts for individual whose logs were not completed. All receipts from 1.10.24 to current will be documented on the monthly logs for this individual.
Residential manager and Controller will review all SNAP logs for each individual in the home to ensure that they are completed and up to date. |
04/05/2024
| Implemented |
| 6400.144 | (Repeated Violation -- 9/26/23) Individual #1 has a PRN prescription for Loperamide. This medication was not present at the home at the time of the 3/21/24 inspection.
Individual #1 had a diabetic eye exam on 2/17/23 with a follow up due in 1 year. As of the 3/21/24 inspection, this examination has not been completed or scheduled. | 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.
| #1 - Residential manager will review all current PRN orders for the individuals in the home to ensure that all PRN medication is present in the home. If the PRN medication is missing, the manager will contact the pharmacy to have it delivered by end of day.
#2 - Residential manager contacted the physician and scheduled a diabetic eye exam to be completed on August 2, 2024. This was the earliest appointment they had but placed the individual on the call list if there is a cancellation.
Director of Programs will review with the residential managers their role after appointments and the steps they are required to take to ensure that all recommendations from the individual's appointments are being implemented. |
04/05/2024
| Implemented |
| 6400.214(b) | At the time of the 3/21/24 inspection, the Individual Support Plan (ISP) available at the home for Individual #2 was dated 5/26/23. The most current ISP is dated 3/5/24. The ISP available at the home for Individual #3 was dated 10/2/23. The most current ISP is dated 2/16/24. | The most current copies of record information required in § 6400.213(2)-(14) shall be kept at the residential home. | Residential managers and/or program specialists will review in HCSIS all current ISPs for the individuals in our residential homes. The manager and/or program specialist will check the plan last updated date on the ISP against the ISP in the individual's binder. If the current ISP is not in the binder, it will be printed, and changes highlighted. The managers and/or program specialists will train staff on the changes in the ISP. |
04/05/2024
| Implemented |
| 6400.32(r)(5) | Individual #2 has a lock on their bedroom door and was not present at the time of the 3/21/24 inspection. The staff present in the home did not have the key to the bedroom on their person and was unsure of the staff key location. | Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door. | Residential manager will assign a central location for all keys to be kept including keys to the individual's rooms. The manager will communicate the location of where the keys are to be kept to the staff in the home.
The manager will review with the staff that the key must be on their person when on shift in case they need to unlock the door to the individual's room in an emergency. |
04/05/2024
| Implemented |
| 6400.163(h) | At the time of the 3/21/24 inspection, Ondansetron was present in Individual #1's medication box, however, this medication was previously discontinued. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Residential manager will review all current medication orders for the individuals in the home to ensure that all current medication is present in the home. The manager will remove any medication that has been discontinued and put it in the discontinued disposable box. If needed, the manager will discontinue the medication on the MAR as required. |
04/05/2024
| Implemented |