| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Poisonous materials such as dish soap and surface cleaners were unlocked under the sink in the kitchen.
Poisons such as cleaners, laundry soap, bath soap, dish soap were in the hallway closet which does not have a lock. The staff #1 stated that they keep the products on the top shelf, so individuals do not get to them.
Poisons were left out in the main bathroom including mouthwash, hand soap, and body wash. | Poisonous materials shall be kept locked or made inaccessible to individuals. | All poisons have been removed from unlocked locations such as the hallway closet. King Family Enterprise added a lock to the storage cabinets at each location. However, it was also confirmed that our individuals are safe around poisonous chemicals as per their Individual Support Plans. |
04/12/2021
| Implemented |
| 6400.71 | There were no emergency numbers listed by the telephone in the living room. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| KFE Program Specialist updated all emergency telephone numbers for each home supported by KFE on April 29, 2021 and placed them near the telephone in each residence. (see attached). |
04/29/2021
| Implemented |
| 6400.77(b) | The following items were not available in the first aid kit at the time of inspection: Scissors, thermometer, tweezers and a first aid manual. | 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. | KFE¿s CEO purchased scissors, thermometer tweezers, and a first aid manual for the First Aid Kid on April 15, 2021. KFE¿s CEO checked each residence first aid kit to ensure all First Aid Kit¿s had the required items as per 6400.77 (b). During the staff meeting held on April 15, 2021. KFE addressed with all employees their job responsibilities including the importance of documenting any missing items in the first aid kit on the Physical Site Inspection Form. |
04/15/2021
| Implemented |
| 6400.113(c) | It cannot be determined that individual #1 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) | It cannot be determined that individual #1 received a physical exam within the past year, as a record of such was not provided at time of inspection. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #1 Annual Physical was completed on 6/26/20 (see attached) |
06/26/2020
| Implemented |
| 6400.142(a) | It cannot be determined that individual #1 received a routine dental exam within the past year, as documentation of such was not provided at time of inspection. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Individual was admitted into our program on 12/11/20. Individual received dental surgery on May 7th, 2021. Individual¿s aunt who is responsible for medical appointments is currently waiting for Dental Surgeon to give her a follow-up date to receive second surgery to remove remaining teeth. King Family Enterprise CEO and Program Director is working with the SC to coordinate a team meeting to discuss overseeing the upkeep and scheduling of all medical appointments for Individual #1. (see attached) |
04/20/2021
| Implemented |
| 6400.144 | It cannot be determined that health services have been provided for Individual #1, as records of medical visits were not provided at time of inspection. | 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.
| King Family Enterprise Program Specialist will ensure the individual¿s health services are scheduled, attended as prescribed and documented and kept in the individuals medical book. King Family Enterprise will also ensure we arrange and provide support to health services appointments. Individual was seen by nephrologist on 2/23/21 for evaluation and to be cleared for dental surgery. (see attached) |
04/22/2021
| Implemented |
| 6400.144 | The following medications for Individual #1 were unavailable at the time of inspection: Polyethylene Glycol, Acetaminophen 500 mg, Mucinex. | 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.
| KFE will ensure that all medication are kept in a central location with individuals names attached. |
05/12/2021
| Implemented |
| 6400.181(a) | It cannot be determined that individual #1 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. | KFE failed to submit all applicable documentation for all individuals supported to the inspectors during the inspection. Individual #1 was admitted into our program on 12/11/20. The Initial Assessment completed and signed on 2/24/21. (see attached) |
02/24/2021
| Implemented |
| 6400.217 | It cannot be determined that individual #1 records contain a signed consent for the release of information, as one was not provided at time of inspection. | 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.
| Individual #1 signed the Authorization of release of information signed on 12/13/20. King Family Enterprise did not properly submit all documentation to inspector during audit. (see attached) |
05/25/2021
| Implemented |
| 6400.183(a)(1) | It cannot be determined that individual #1 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. ISP invite letter indicated ARU meeting was scheduled for 2/23/21. |
04/19/2021
| Implemented |
| 6400.213(1)(i) | It cannot be determined that individual #1 individual record contains the following items: his admission date, Social Security number, religious affiliation, race, and 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. | King Family Enterprise Program Specialist created a face sheet on April 23, 2021 for individual #3 that contains all information as per 6400.213 (1) (i) (see attached) |
04/23/2021
| Implemented |