| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(2) | Individual disbursements for the individual 1 were not documented or distinguished between home cleaning items. Monthly ledger showing itemized transactions were also not kept other than the month of January in the past 6 months. IT is unknown if all transactions were made solely for the individual. | (2) Disbursements made to or for the individual.
| At the end of each month, the monthly ledger sheet and any left over monies are returned to the office for reconciliation. The spending cash for the new month is then disbursed to the home. Any previous records (dating back to 6 months) will be located with Finance at the office. Staff were also trained to record each transaction on the ledger sheet; having the receipt of purchase is not enough. House Supervisors have been instructed to include the audit of the spending cash and MAR as part of their daily inspections. Lastly, receipts for grocery or cleaning supplies must be submitted to the house supervisor and no longer stored with receipts for consumer spending cash. All of this was addressed in the all staff training conducted on 2/14/2020. |
02/14/2020
| Implemented |
| 6400.62(a) | Ajax detergent tabs were found in the living area's closet unlocked. They were locked by agency during inspection after locating them. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The need for all storage locations to be locked was addressed at the all staff training conducted on 2/14/2020. Padlocks have been purchased and locks installed in all the homes, and staff have been trained on it |
02/14/2020
| Implemented |
| 6400.64(a) | The interior of the oven and the stove top in the kitchen were stained with dirt and grease residue.
The bathroom ceiling had Mildew build up that needs to be cleaned. | Clean and sanitary conditions shall be maintained in the home. | The interior of the oven was cleaned on 2/13/2020 with the use of oven spray can. The top of the stove was given a good scrub and wipe down the evening of the inspection (1/15/2020). The maintenance team at the apartment building was notified about the mildew at the top of the bathroom. A technician was sent out to look at it but the fix will be completed by end of next week. |
02/21/2020
| Implemented |
| 6400.67(a) | The window blinds were damaged in individual 1's room. | Floors, walls, ceilings and other surfaces shall be in good repair. | A new window blind has been purchased and scheduled for installation by the Provider's handyman by 02/21/2020 |
02/21/2020
| Implemented |
| 6400.67(b) | The shower enclosure was broken and could pinch or cause harm to the individual. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The shower enclosure has been fixed by the maintenance team of the apartment building. |
02/11/2020
| Implemented |
| 6400.76(a) | Dryer lint was found in the dryer at the time of physical site inspection. | Furniture and equipment shall be nonhazardous, clean and sturdy. | New signs have been printed, laminated and put up beside each dryer in the homes regarding lint removal after each drying session. This topic was also addressed in the all staff meeting training conducted on 2/14/2020 |
02/14/2020
| Implemented |
| 6400.77(b) | A thermometer was not found in the first aid kit at the time of physical site inspection. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | A new thermometer was purchased and delivered to the home. Additionally, the first aid box has been added to the inventory count for House Supervisors to check on weekly |
01/17/2020
| Implemented |
| 6400.144 | A Dental appointment on 5/9/18 requested a follow up appointment on 11/14/18 by the dentist. The appointment wasn't kept, the next appointment was not held until 7/15/19. | 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.
| A CAP was already put in place back in early 2019 that mandated all medical appointments to be entered in the calendar of the Executive Director and Supervisors. In addition, each medical appointment is set up with a 1 day reminder in advance. All medical appointments for each week are reviewed in the prior week and the appointment forms are filled out and sent to the homes for staff to utilize. |
02/14/2020
| Implemented |
| 6400.32(h) | A video capturing camera was located in the main living area of individual 1. The camera was installed in the residence without documentation of notice, consent from the individual and who controls the technological device. The purpose of the device was not clear and there was no individual centered plan on why device was installed nor any outcomes to achieve greater independence and privacy for individual 1.
Agency stated camera was turned off at the time of inspection. | An individual has the right to privacy of person and possessions. | The original purpose was an added measure to ensure the health and safety of the individuals. More specifically, it helped with any incidents of abuse or neglect reported in a timely fashion (within the last 72 hours of when the incident occurred) as we are able to view any motion movements detected by the camera. The video camera is unplugged. Also, an EIM has been entered regarding this and it is under investigation.
Going forward and with the release of the Regulatory Compliance Guide (RCG), we have been scheduling team meetings with the SCs, family members and Behavioral Specialists of the individuals and are using the technology guide of the RCG to determine if we are keeping or disconnecting the cameras. |
02/14/2020
| Implemented |
| 6400.166(b) | Medication for individual #1 was not logged immediately after administration. No code provided on the log explaining blank entries.
The following medication was not logged as administered on the following corresponding dates:
1. Risperidone 2mg tablet to be taken twice daily - not logged 1/2/2020 at 8am, 1/1, 1/2, 1/3, 1/4 and 1/7/2020 at 8pm
2. Divelproex 500 mg to be taken twice daily - not logged 1/2 and 1/3/2020 at 8pm
3. Clotrimazole cream 1% to be applied twice daily at 8am and 8pm - not logged 1/2, 1/3, 1/4, 1/5 1/7, 1/10, 1/11, 1/12, 1/13, 1/14 and 1/15/2020 at 8am and 1/2, 1/3, 1/9, 1/10, 1/11, 1/13 and 1/14/2020 at 8pm
4. Triamcinolon cream .1% to be applied topically twice a day at 8am and 8pm - not logged 1/2, 1/3, 1/4, 1/5, 1/7, 1/10m, 1/11, 1/12, 1/14 and 1/15/2020 at 8am and 1/2,1/3, 1/9, 1/10, 1/11 and 1/13/2020 at 8pm
5. nystatin 100000 cream to be taken 3 times a day at 8am , 4pm and 8pm - not logged on 1/2-1/5/2020, 1/7, 1/10-1/12, and 1/14/2020 at 8am; 1/2, 1/3, 1/9-1/11, and 1/13/20 at 4pm; and 1/2, 1/3, 1/9, 1/10, 1/11 and 1/13/2020 at 8pm | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | An all staff training was done on medication administration and logging of information on the MAR. Also, a new policy was put in place where an error by any staff will trigger a retraining but repeat offenders will be given a written warnings which could lead to termination |
02/14/2020
| Implemented |