| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(c) | The agency's self-assessments were reviewed. Each self-assessment reviewed reported violations in numerous areas, but it cannot be determined that a written summary of corrections for those violations has been kept in the agency's records, as they were not provided at time of inspection. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| KFE did not accurately completed the self-assessment. We failed to plan accordingly and adequately complete the tool. KFE has implemented a policy to ensure the self-assessment is completed bi-annually by the Program Director and reviewed by the CEO. The CEO will submit the self-assessment to licensing within 3-6 months prior to the expiration of our certificate of compliance. |
04/15/2021
| Implemented |
| 6400.77(b) | There was no thermometer in the first aid kit at time of 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. | The thermometer was purchased and added to each first aid kit that was missing one on April 15, 2021. |
04/15/2021
| Implemented |
| 6400.82(e) | There were two bathrooms in the apartment, one with a shower and the other with a tub. Both bathrooms did not have nonslip matts in the tub or shower. | Bathtubs and showers shall have a nonslip surface or mat. | Nonslip surface mats were purchased and placed in each residence bathroom on April 22, 2021. (see attached) |
04/22/2021
| Implemented |
| 6400.113(c) | It cannot be determined that individual #2 has received fire safety training, as records of that training were not provided at time of inspection. | A written record of fire safety training, including the content of the training and a list of the individuals attending, shall be kept. | Fire safety training will be held on May 27, 2021 for all individual¿s receiving residential services from our organization. |
05/27/2021
| Implemented |
| 6400.141(a) | The date of individual #2 most recent physical cannot be fully determined as documentation submitted at time of inspection contained multiple dates: the exam was dated 6/20/20 on its first page, references the date 6/26/20 on its second page, and was signed by the doctor on 1/18/21. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Direct care staff member dated physical form incorrectly, however medical visit summary report is consistent with the date of 6/26/20 and documents annual physical exam was completed on that date. (see attached) |
06/26/2020
| Implemented |
| 6400.142(f) | It cannot be determined that individual #2 has a dental hygiene plan, as one was not provided at time of inspection. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | Individual #2 was discharged from program on 4/11/21. Hygiene plan was created on 4/12/21 however individual was not present at the residence to sign due to no longer wanting to reside in a residential setting. Individual moved with a family member. |
04/21/2021
| Implemented |
| 6400.181(a) | It cannot be determined that individual #2 has been assessed by the agency annually as assessment documentation was not provided at time of inspection. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Individual #2 is no longer with us however KFE will ensure that all individuals will receive an annual assessment as per 6400 181(a) |
04/15/2021
| Implemented |
| 6400.216(a) | There was no lock on the office that contained the records for the individuals. The program books were not locked inside of the office either. | An individual's records shall be kept locked when unattended.
| New cabinets and locks were added to all sites effective May 5, 2021. Staff are provided with a key to locked cabinets to be stored in the staff office space in a locked key box. |
05/05/2021
| Implemented |
| 6400.31(b) | It cannot be determined that the agency provided individual #2 the education or accommodation needed for him to make choices or to understand his rights, as documentation of such was not provided at time of inspection. | The home shall educate, assist and provide the accommodation necessary for the individual to make choices and understand the individual's rights. | Individual #2 was discharged 4/13/21 before individual rights could be reviewed and signed with him. |
04/12/2021
| Implemented |
| 6400.183(a)(1) | It cannot be determined that individual #2 plan was developed by an interdisciplinary team, as records regarding his plan and plan meeting were not provided at time of inspection. | The individual plan shall be developed by an interdisciplinary team, including the following: The individual. | KFE contacted the SC to obtain a copy of the ISP signature page and invite letter via email. |
05/17/2021
| Implemented |
| 6400.213(1)(i) | Individual #2 record does not include his race, Social Security number, or next of kin. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | A Face sheet was created for the individual on January 4, 2021 however, it did not contain all pertinent information per 6400.213. Therefore, KFE updated Face sheets for all individual on 4/30/21. Individual #2 was discharged on 4/13/21. |
04/13/2021
| Implemented |