| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency completed a self-assessment 1/24/2023, 7/23/2023, 1/10/2024 and not within 3 to 6 months prior to the expiration date of the agency's certificate of compliance. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| The management team(Site Supervisor, Compliance Specialist and Program Specialist) were trained on the self assessments and completion of self assessment tool in regards to regulation.15(a). |
02/05/2024
| Implemented |
| 6400.141(c)(7) | Individual #1, date of admission 5/13/2019, had a gynecological examination completed 5/26/2023 and not prior. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | The Management team was trained on regulation 6400.141 (C)(7) Individual Physical
Examinations 2/5/24. The Program Specialist reviewed the preventative schedule for women
2/1/2024. On 2/1/2024 the Program Specialist scheduled a 2024 gynecological
exam for the individual for 5/28/2024. The appointment was placed on the agency appointment calendar for the individuals 2/1/2024. |
02/05/2024
| Implemented |
| 6400.214(b) | On 1/31/2024, Individual #1's record did not include: Incident reports relating to the individual, dental examinations, dental hygiene plan, assessment, and copies of psychological evaluations. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| On 2/5/23, The management team was trained on regulation 6400.214.(b)The individuals binder was in the office and placed back in the home with the appropriate documentation assessable such as; dental examinations, dental hygiene plan, assessment, and copies of psychological evaluations. |
02/05/2024
| Implemented |
| 6400.32(e) | On 1/31/2024 Individual #1's knives were locked in the medication closet. | An individual has the right to make choices and accept risks. | On 1/31/24, the Site Supervisor removed knives from the medication box. On 2/5/24, Management team and staff were trained on 6400.32(e) regulation. |
02/05/2024
| Implemented |
| 6400.32(r)(4) | On 1/31/2024, Individual #1 had a turn privacy lock on the inside of the bedroom door, which did not allow easy and immediate access by the individual and staff persons in the event of an emergency. | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. | On 2/5/24, the management team (CEO, Site Supervisors, Site Supervisor and Compliance Specialist) were trained on regulation 6400.32(r) (4). On 2/12/24, the individuals door nobs were changed to ensure a keyed entry for the individual. |
02/12/2024
| Implemented |
| 6400.161(d) | Individual #1's assessment completed 5/13/2023 states the individual is unable to self-administer medications. Individual #1's individual support plan, last updated 8/22/2023, states the individual does not take her medications regularly, without supervision. Individual #1 currently self-administers Diabetic Insulin injections subcutaneously. | The individual plan must identify if the individual is unable to self-administer medications. | On 2/6/24, Program Specialist updated the individuals ISP to add that she can self administer her Diabetic Insulin injections. The managment team and staff were trained per regulation 6400.161 (d) The updated ISP was sent to her Program Specialist. A message was sent to the staff to allow the individual to complete the MARS whenever she self administers. |
02/06/2024
| Implemented |
| 6400.165(c) | Individual #1 is prescribed Levothyroxine 50mcg Tab, "Take 1 tablet every morning on an empty stomach for Hypothyroidism" and Metformin 100mg Tab, "Take 1 tablet by mouth twice a day with breakfast and dinner for Diabetes". During the inspection conducted 1/31/2024 Individual #1's January 2024 medication administration record documented the Levothyroxine, and the Metformin were administered at 8:00AM from 1/01/2024 through 1/31/2024. | A prescription medication shall be administered as prescribed. | On 2/1/24, Program Specialist Reached out the to the PCP to request the individuals record be reviewed to have the medication administration time for the Levothyroxine administration time changed to reflect 7:00am 1 hour before breakfast. The PCP assessed medication and sent a letter to the PS 2/8/2024 updating the new time for the Levothyroxine to 7:00AM. The pharmacy was notified by the PCP. The pharmacy sent the updated MAR page to the PS that shows the 7:00AM admin time. The PS discontinued the old administration time an added the new administration time 2/8/2024. The Program Specialist placed sign regarding the new Levothyroxine time 2/8/2024. The PSS sent electronic notification to staff 2/12/2024. |
02/12/2024
| Implemented |
| 6400.166(a)(15) | Individual #1 is prescribed Senna 8.6 Tablet, "Take 2 tablets at bedtime as needed for constipation" and Peg 3350, "Mix 17GMs of powder in 8ox of water or juice and give by mouth daily as needed for constipation. During the inspection conducted 1/31/2024, Individual #1's January 2024 medication administration record did not include special precautions with the medications by defining when to take the medications and if the medications can be administered simultaneously or not. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Special precautions, if applicable. | On 2/1/2024, PS reached out the to the PCP to request the individuals record be reviewed for the administration of MiraLAX powder and Senna tab medications for constipation medications for special precautions. On 2/1/2024, The Provider assessed medication and sent a discontinue of the MiraLAX powder effective 2/1/2024 to PS. The discontinue was also sent to the pharmacy 2/1/2024 the PS
confirmed it was received. The MiraLAX was discontinued on the PRN page of the MAR 2/1/2024. Staff was notified of the discontinue and the MiraLAX was disposed 2/1/2024. |
02/01/2024
| Implemented |
| 6400.207(4)(I) | Individual #1 is prescribed Hydroxyz HCL 50mg Tab, "Take 2 tablets by mouth twice a day as needed for Schizoaffective Disorder, Bipolar type. During the inspection conducted 1/31/2024 Individual #1's January 2024 medication administration record did not include written instructions by a physician or medical practitioner listing the individual's specific symptoms of the psychiatric diagnosis that would warrant the use of the medication. | A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition. | Reached out the to the Psych provider 2/1/2024 to request the individuals record be reviewed to have written instructions developed to include (symptoms, diagnosis to warrant use) or the need for continued the PRN medication. The Provider assessed the medication(Hydroxyz) and sent a discontinue of the Hydroxyz as the Individual has not required the PRN medication in
more than 16 months. A discontinue was sent 2/8/2024 to the pharmacy and a copy to the
Program Specialist. The provider will reassess prescribing a PRN medication
for the individual if ever needed. The PRN medication was discontinued on the MAR and discontinued and disposed 2/8/2024. |
02/08/2024
| Implemented |