| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.80(a) | On 1/11/2023 the walkway leading to the exterior stairway on the side of the home have four cement pavers that are uneven, presenting a tripping hazard. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | Operation Manager leveled the ground in front of step area where the pavers were placed for use of a sidewalk, Pavers were reset and OM assured they were level and no risk of trip/fall. [Documentation of the leveled-out walkway, via photograph, was received on 3/16/23 and reviewed 3/17/23. Documentation of quarterly monitoring form, dated 2/10/23, was received 3/16/23 and reviewed 3/17/23. DPOC by HDKP, HSLS, on 3/22/23]. |
02/01/2023
| Implemented |
| 6400.181(a) | Individual #1 was admitted on 3/3/2022 and the initial assessment was completed on 5/23/2022, 81 calendar days after admission. | 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. | Program Specialist, reviewed Programming regulations,(which included 6400.181(a)) to assure knowledge of required timelines. Signature/content was sent to HR Department. [Documentation of staff training related to initial and annual individual assessments, dated 1/30/23, was received on 3/16/23 and reviewed 3/17/23. DPOC by HDKP, HSLS, on 3/22/23]. |
01/30/2023
| Implemented |
| 6400.214(b) | On 1/11/23 Individual #1's most recent assessment and psychological evaluation were not present at the home. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| On 1/11/2023, a RESIDENTIAL RECORDS binder was created: Binder contains
Individual Demographics (ID Sheet), individual Assessments, most recent phycological evaluation, annual physical, dental hygiene plan, recent incident reports(90days) was placed in all service locations, this will assure compliance with 6400.214(b) |
01/11/2023
| Implemented |
| 6400.165(b) | Individual #1's, date of admission 3/03/2022, January 2023 Medication Administration Record states, "Ketoconazole 2% Shampoo, apply to scalp three times a week and let sit for five minutes and then rinse; taper to as needed with flares." The medication label states, "Ketoconazole 2% Shampoo, apply liberally as directed to scalp once per week." Individual #1's January 2023 Medication Administration Record states, "Benzoyl Peroxide, 5% Wash, use as a face wash at bedtime for acne." The medication label states, "Benzoyl Peroxide 5% Wash, apply a small amount to skin at bedtime for acne." | A prescription order shall be kept current. | Prescription for Ketoconazole 2% shampoo and Benzoyl Peroxide 5% were corrected on the MAR to match the prescription label on the prescribed medication. [Documentation of quarterly monitoring form the includes MAR checklist, dated 2/10/23, was received 3/16/23 and reviewed 3/17/23. DPOC by HDKP, HSLS, on 3/22/23]. |
02/09/2023
| Implemented |
| 6400.166(a)(2) | Individual #1's January 2023 Medication Administration Record does not list the prescribing physician. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | The MAR for Individual #1 was corrected to include the name of the prescribing physician. [Documentation of quarterly monitoring form the includes MAR checklist, dated 2/10/23, was received 3/16/23 and reviewed 3/17/23. DPOC by HDKP, HSLS, on 3/22/23]. |
01/16/2023
| Implemented |