| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency's Certificate of Compliance expiration date was 8/19/2022. The agency completed the self-assessment of the home on 11/28/2022. | 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.
| Self-assessments were completed, however not within a timely manner. CEO and Program Specialist will complete future self-assessments within the required timeframe of 3 to 6 months prior to expiration date of the certificate of compliance. CEO and Program Specialist will complete all self-assessments by 5/19/23 and will begin self-assessments no later than 3/1/23 to measure compliance with applicable regulations and correct any identified deficiencies. Violations will be identified, and written summaries of corrective actions taken will be documented. |
03/01/2023
| Implemented |
| 6400.15(c) | Violations were identified by marking the "V" on the self-assessment; however, the agency did not identify the violations and complete a written summary of corrections made. | 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.
| Self-assessments were completed, however not within a timely manner. CEO and Program Specialist will complete future self-assessments within the required timeframe of 3 to 6 months prior to expiration date of the certificate of compliance. CEO and Program Specialist will complete all self-assessments by 5/19/23 and will begin self-assessments no later than 3/1/23 to measure compliance with applicable regulations and correct any identified deficiencies. Violations will be identified, and written summaries of corrective actions taken will be documented. |
03/01/2023
| Implemented |
| 6400.112(c) | The home held a fire drill on 2/21/2022 and a total evacuation time was recorded as 12.15. The home held another fire drill in July 2022; however, the date of the drill was not recorded. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | All staff at each site will be re-trained on the requirements of conducting fire drills at least monthly and the importance of completing the documentation of the fire drill completely and correctly. CEO will develop documentation to be utilized at each site and by all staff for reference for conducting a fire drill and properly completing the accompanying paperwork. New/updated fire drill records have been developed and have been distributed to each house to aid in improving fire drill safety. |
03/01/2023
| Implemented |
| 6400.141(c)(1) | Individual #1's physical examination, completed 2/16/2022, did not include a review of previous medical history. | The physical examination shall include: A review of previous medical history. | CEO and program specialist will conduct audit of all individuals' files for compliance purposes. Any issues/noncompliance identified during the audit will be immediately corrected. CEO will develop a checklist for continued monthly monitoring by CEO and program specialist of all individual files in order to maintain compliance in the future. All staff, especially house managers, will be trained on the importance of completing all areas of medical records/documentation at the time of examination. |
03/01/2023
| Implemented |
| 6400.141(c)(4) | Individual #1's physical examination completed 2/16/2022, did not include a vision screening. The physician recommended further vision testing. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Vision screening to be scheduled immediately along with physical examination due by 2/16/23 and TB screening. CEO and program specialist will conduct audit of all individuals' files for compliance purposes. Any issues/noncompliance identified during the audit will be immediately corrected. CEO will develop a checklist for continued monthly monitoring by CEO and program specialist of all individual files in order to maintain compliance in the future. All staff, especially house managers, will be trained on the importance of completing all areas of medical records/documentation at the time of examination. |
03/01/2023
| Implemented |
| 6400.141(c)(6) | Individual #1's physical examination completed 2/16/2022, did not include tuberculin testing. | 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. | TB will be scheduled immediately along with annual physical examination. CEO to develop checklist for monitoring individual files on a monthly basis. CEO and program specialist will conduct an audit of all files at least monthly to ensure compliance with applicable regulations. Any issues/noncompliance identified during the audit will be immediately corrected. CEO will develop a checklist for continued monthly monitoring by CEO and program specialist of all individual files in order to maintain compliance in the future. All staff, especially house managers, will be trained on the importance of completing all areas of medical records/documentation at the time of examination. |
03/01/2023
| Implemented |
| 6400.141(c)(7) | Individual #1's most recent gynecological examination was completed on 7/1/21. | 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. | Gynecological exam was completed, and documentation was found for examination. Examination was done on 10/20/2022, past the required timeframe as specified by regulation requirements. Documentation will be forwarded for inspection purposes with POC. Program specialist will be distributing to each site manager, a list of required annual medical appointment dates. House managers will be responsible for scheduling necessary appointments within the timeline specified by program specialist. CEO and program specialist will conduct monthly checks at each house to ensure appointments are scheduled in timely manner in order to maintain compliance. |
03/01/2023
| Implemented |
| 6400.151(a) | Direct Service Worker #1 had a physical examination completed on 7/26/2019 and then again on 8/16/2021. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Physical examination for DSP was completed however not within the regulatory timeframe required. CEO will develop a checklist for CEO and program specialist to perform staff file audits on a monthly basis in order to prevent reoccurrence in the future. All current staff files will be audited on a monthly basis to ensure continued compliance of applicable regulations. |
03/01/2023
| Implemented |
| 6400.151(c)(2) | Direct Service Worker #1 had a tuberculin screening completed on 7/26/2019 and then again on 8/16/2021. [Repeat violation 12/20/2021 et al] | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | Physical examination which included TB screening for DSP was completed however not within the regulatory timeframe required. CEO will develop a checklist for CEO and program specialist to perform staff file audits on a monthly basis in order to prevent reoccurrence in the future. All current staff files will be audited on a monthly basis to ensure continued compliance of applicable regulations. |
03/01/2023
| Implemented |
| 6400.171 | On 11/30/2022, a half-gallon of orange juice with an expiration date of 11/23/2022 was in the refrigerator in the kitchen of the home. | Food shall be protected from contamination while being stored, prepared, transported and served.
| Discarded at time of inspection. CEO will post reminder that all staff are responsible for checking and monitoring refrigerator, freezer and all cabinets for food expiration dates and that any items nearing expiration date to be discarded according to expiration date. House managers will be responsible for performing weekly check and signing off that monitoring is being done and is maintained. CEO will develop checklist for monitoring purposes and along with program specialist will monitor sites monthly for compliance. Training to be conducted to remind all staff of importance of weekly monitoring for food safety. |
03/01/2023
| Implemented |
| 6400.214(b) | Individual #1's most recent physical examination and dental examination are not being kept in the home. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| All documentation that is required to be kept in the home is there currently. House managers will be trained on what documentation is required to be kept in the home and will be responsible for monthly monitoring to ensure compliance. CEO to develop checklist to aid house managers in monitoring for compliance. CEO and program specialist will be responsible for site monitoring on monthly basis to ensure compliance and that checks are being completed. |
03/01/2023
| Implemented |
| 6400.46(d) | Direct Services Worker #1 completed first aid, cardio-pulmonary resuscitation, and Heimlich techniques training on 8/26/2019 and then again on 12/3/2021. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Providers CPR/first aid trainer has developed a checklist of all staff and their required renewal dates. Checklist is posted in the office and also kept by trainer. Any new staff persons hired will be immediately added to the checklist to maintain compliance in the future. CPR/First Aid certified trainer will then conduct a monthly review of the checklist and all new hires to ensure continued compliance with applicable regulatory requirements. |
03/01/2023
| Implemented |
| 6400.165(g) | Individual #1, date of admission 4/7/21, who is prescribed medications to treat symptoms of a psychiatric illness has not had a review of the medications by a licensed physican.[Repeat violation 12/20/2021 et al] | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Psychiatric review to be scheduled with psychiatrist which will include documentation of the reason for prescribing the medication, the need to continue the medication and the necessary dosage. House manager will be responsible for ensuring all three-month reviews of all medications prescribed to treat psychiatric illness are completed filled out by psychiatrist at time of examination/evaluation. CEO and program specialist will then be responsible for performing monthly audits of all individual files for compliance in this area. |
03/01/2023
| Implemented |
| 6400.166(b) | Vitamin D2 1.25mg., take 1 capsule by mouth once a week on Saturday prescribed to Individual #1 was not initialed as administed on Saturday, 11/26/2022. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Provider medication administration trainer to conduct a medication training review with all staff at each house. Training completing documentation will be kept on file in the office and in each staff training record. |
03/01/2023
| Implemented |