| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.111(c) | The fire extinguisher located in the kitchen did not meet the requirements which is a 2A rating. The fire extinguisher in the kitchen was a 1A rating. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | The CEO purchased new 2A-10BC fire extinguishers which were placed and serviced in the home on 10/28/2021. (see attached photo). |
10/28/2021
| Implemented |
| 6400.141(c)(6) | It cannot be determined if Individual #3 had a Tuberculin (TB) test since her admission on 03/29/21. However, Individual #3 had a telephone medical visit on 3/02/21. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | MJHC Program Specialist contact Individual's Primary Care Physician on 09/20/2021 to schedule a TB test. The TB test has been scheduled for 11/30/2021 as this is the earliest appointment available. |
09/20/2021
| Implemented |
| 6400.144 | Individual #3 had a telephone medical visit on 3/02/21and it was indicated that she needed to have a gynecological exam and lab work done. To date no follow-up was recorded or documented in her record. | 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.
| Individual #3 completed a Gynecological exam on 10/7/21 (see attached) |
10/07/2021
| Implemented |
| 6400.151(c)(3) | Staff #1 10/28/20 physical does not include a signed statement clearing them of communicable disease. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | MHJC Human Resources Director has updated the Staff Physical Examination form to includes a statement where the physician has to document Yes or No to ¿is staff persons is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals?¿ (see attached form). |
09/27/2021
| Implemented |
| 6400.151(c)(4) | Staff #1 10/28/20 physical does not address whether or not they have any health conditions that might interfere with the health of the individuals they work with. | The physical examination shall include: Information of medical problems which might interfere with the health of the individuals. | Staff #1 is no longer employed with MJHC effective 9/22/2021. The Human Services Director and the CEO met on 9/22/2021 to review the staff physical from. The form was updated on 9/27/2021 to meet the requirements as per 6400.151 (c) (1-4). |
09/27/2021
| Implemented |
| 6400.161(b) | There is no assistance being given to Individual #3 who Self-Administers medication. No reminder of schedule for taking medication, provide or arrange for assistive technology. If Individual #3 refuses to take medications the agency has nothing in place to monitor this behavior or to forward to the doctor or team. Medication being taken by Individual #3 is SERTRALINE and DOXEPIN. | Assistance in the self-administration of medication includes helping the individual to remember the schedule for taking the medication, offering the individual the medication at the prescribed times, opening a medication container and storing the medication in a secure place. | The Program Specialist created a one-page reminder document specifically of Individual #3 (see attached in email). The CEO met with Individual #3 on 9/27/2021 to review all of the medications, as well as the newly created MAR for the individual to sign and to discuss the importance of taking medications as prescribed. Individual #3 was presented with the 1 page document to post in her room for daily reminders. During the staff meeting held on 9/30/2021 via zoom (see agenda- sign in sheet) we discussed the importance of reminding and providing assistance to Individuals who both self-administer and those who do not as well as proper medication administration documentation and administration. |
09/27/2021
| Implemented |