| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | The financial record was not current and up-to-date. In March 2022, there was a mathematical error that occurred, leaving the current account balance over by .89 cents. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | The agency has changed its practice on how financial documents are double checked. House managers are required to complete checks of each completed hand written cash count sheet from each home and provide their initials on the back of receipts and signature at the bottom of the page. They are then required to type this information into the online reconciliation forms. |
07/20/2022
| Implemented |
| 6400.113(a) | Individual #1 moved into the home on 7/19/21 and did not receive the initial fire safety training until 7/21/21. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | The program specialist has been trained on initial and annual fire safety training requirements |
07/18/2022
| Implemented |
| 6400.165(e) | Individual #1's prescription medication Linzess was discontinued on 3/12/22 and then restarted on 3/24/22. There is no written order from the prescriber ordering this discontinuance and subsequent restart. | Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received. | The agency was able to obtain documentation that the Linzess was discontinued and restarted. The guardian of individual took them for the appointment and did not have information completed that is needed by the agency. The house managers have been trained on new procedures in regards to others taking individuals to doctor's appointments, including guardians/parents. Managers are now required to schedule staff to attend the appointment and ensure appropriate documents are completed prior to leaving, even if the guardian or individual does not allow the staff to be present during exams. This includes written changes of medication on the medical forms. |
07/20/2022
| Implemented |
| 6400.165(g) | (Repeat Violation -- 7/9/21) Individual #1 had a quarterly medication review on 7/19/21 and not again until 12/22/21. | 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. | The individual had an appointment on 9/23/21 for a psychiatric medication review. This appointment was a telehealth appointment and appropriate documentation was not obtained by the supporting staff. That staff is no longer employed with the agency. The house managers, who are responsible for medical appointments have been retrained on appropriate documentation of psychiatric appointments. In addition, the agency has added new employees to the role of residential coordinator recently. These coordinators are responsible for the oversight and review of medical appointments and documentation within 24 hours of the appointment. Lastly, the program specialist is trained to review these documents for accuracy no more than three business days following the appointment. |
07/20/2022
| Implemented |
| 6400.167(a)(1) | Individual #1 did not receive their prescribed medication Linzess from 3/13/22 through 3/23/22. | Medication errors include the following: Failure to administer a medication. | The agency has obtained the discontinuation documentation from the appointment the individuals guardian took him too. The agency has begun new practice in regards to guardians/families or others outside the agency taking individuals to appointments. Staff will attend all appointments, even if the individual declines their participation in the appointment, staff will be on premises to obtain appropriate documents needed and ensure accurate medical information is obtain at the end of the appointment |
07/21/2022
| Implemented |
| 6400.167(c) | The failure to administer Linzess to Individual #1 from 3/13/22 through 3/23/22 was not reported as an incident. | A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). | The agency has obtained the discontinuation documentation from the appointment the individuals guardian took him too. The agency has begun new practice in regards to guardians/families or others outside the agency taking individuals to appointments. Staff will attend all appointments, even if the individual declines their participation in the appointment, staff will be on premises to obtain appropriate documents needed and ensure accurate medical information is obtain at the end of the appointment |
07/21/2022
| Implemented |