Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.142(a) | Individual #1 had a dental examination completed 9/30/2020 and not again since. (Repeated Violation-1/06/2021, et al). | 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. | The Residential Manager has been instructed make a dentist appointment for individual #1, for the first available appointment. Director of Operations has reviewed regulation 6400.142(a), 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, with the Residential Manager to ensure the understanding compliance of the regulation. |
02/04/2021
| Implemented |
6400.144 | Individual #1's physical examinations completed 8/07/2020 and 9/16/2021 states the individual's hearing was unable to be tested. No documentation was provided on any further hearing examinations or refusals. | 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.
| Residential Manager has been instructed to contact Individual #1's PCP to get information regarding on the inability for his hearing to be tested, and to get documentation for further hearing exams. Director of Operations has reviewed Regulation 6400.144 - 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, with the Residential Manager and the importance of Compliance. |
02/04/2022
| Implemented |
6400.181(e)(12) | Individual #1's assessment completed 9/20/2021 did not include: Recommendations for specific areas of training, programming and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | KZL Agency has revised and updated Residential Annual Assessment to ensure all information as noted in Chapter 6440.181(e) is reflected, including specific recommendations for specific areas of training, programming, and services. KZL Agency Residential Program Specialist will begin using this revised assessment immediately, replacing the old assessment. |
01/26/2022
| Implemented |
6400.34(a) | Individual #1's most recent signed copy of rights completed 12/16/2020, did not include the following rights: 6400.32e through 6400.32g, to choose, accept risks, refusal and control the individual's schedule, activities and services; 6400.32j to voice concerns and 6400.32k to participation in the development and implementation of the individual plan; 6400.32r and 6400.32s relating to locking doors in bedrooms and in the home. | 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. | KZL Agency has revised and updated our agency Individual Rights policy to include all rights as noted in Chapter 6400 and Chapter 6100 regulations. KZL Agency has already been following the guidelines in the residential homes but had not updated written policy to reflect these guidelines. KZL Agency will ensure that this updated policy is what is shared with individuals going forward. |
12/03/2021
| Implemented |
6400.163(d) | During the on-site inspection conducted 12/03/2021 Equate Stomach Relief 16fl oz and Nyquil 12fl oz were located in the living room, unlocked under a shelf. Individual #1's assessment completed 9/20/2021 states the individual is unable to self-administer medications. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | The medications that were located in the living room, unlocked under a shelf was immediately placed with the rest of the medications in a locked area. Regulation 6400.163(d) ¿ Prescription medication and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked was reviewed with staff. A house-checklist was put into place to ensure that prescription medication and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. |
02/04/2022
| Implemented |
6400.165(g) | Individual #1 had a psychiatric medication review 1/20/2021 and then again 5/05/2021. Individual #1's psychiatric medication reviews completed 1/20/2021, 5/05/2021, and 7/30/2021 did not include the physician's signature and credentials. | 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. | KZL Agency has revised its psychiatric medication review documentation to include the physicians¿ credentials, the reason for prescribing the medication, the need to continue the medication and the necessary dosage |
02/01/2022
| Implemented |
6400.166(a)(9) | Individual #1 is prescribed Ibuprofen 200mg tablet, with instructions to take 1 tablet every 4 to 6 hours as needed for minor aches, pain, and fever. Individual #1's December 2021 medication administration record states to take 1 tablet every 6 hours as needed. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | Individual#1's MAR was corrected to state take one (1) tablet every 4-6 hours as needed. Do not exceed six (6) tablets in a 24-hour period. All other medications were checked to ensure the instructions on the MAR coordinated with the instructions of the medication prescribed. |
02/04/2022
| Implemented |