Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.112(e) | A sleep drill has not been held since December 2021 | A fire drill shall be held during sleeping hours at least every 6 months. | A sleep drill was completed on 10/13/2022 at asleep hours to correct the citation. Additionally, a recurring reminder has been set up in the company calendar for all House supervisors and Program Manager to be alerted to perform a fire drill once every six months for each home in the program during asleep hours. |
10/13/2022
| Implemented |
6400.217 | For individual 3, there was no signed release of information provided. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| A sIgned release of information form was provided for the individual to sign right after the inspection was completed. |
09/28/2022
| Implemented |
6400.34(a) | For individual 3, the provided consent forms are past due, with those dated 1/4/21 | 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. | New consent forms were provided for the individual to sign right after the inspection was completed. |
09/28/2022
| Implemented |
6400.34(b) | For individual 3, the provided bill of rights is not dated on the signature line, making it impossible to determine if this was provided and reviewed with the individual within the compliant annual time frame. | The home shall keep a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights. | New bill of rights form was provided for the individual to sign and also explained to the individual right after the inspection was completed. |
09/28/2022
| Implemented |
6400.165(b) | PRN medication (ACETAMINOPHEN 325mg and BENZONATATE 100mg) was in individual 3's medication box and not listed on the MAR.
PRN medication (ROBAFEN DM) is listed on individual 3's MAR and not in the medication box at time of inspection. | A prescription order shall be kept current. | The acetaminophen and Benzonatate were discarded from the box immediately after the inspection. |
09/28/2022
| Implemented |
6400.166(b) | For individual 3, the 8pm dosage medication (SENNA 8.6mg and TRAZODONE 50mg) was not logged as administered. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The staff responsible for administering the medication was retrained on med administration documentation |
09/28/2022
| Implemented |