| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | On 8/31/2023, at approximately 12:10PM, the following poisonous materials were unlocked and accessible in the staff office which is only able to be locked from inside the room: two one-quart spray bottles of Spic and Span Antibacterial Cleaner, a 23 fluid ounces spray bottle of Windex with Vinegar, a 23 fluid ounces spray bottle of Windex, and a 9.7 ounce can of Pledge cleaner. Individual #1's Individual Support Plan, last updated 8/15/2023, states chemicals such as cleaning products are kept locked. Interviews reveal that the staff office is not always locked because staff are not able to gain entry to the room when the door is locked | Poisonous materials shall be kept locked or made inaccessible to individuals. | An email was sent on 8/31/2023 to reflect the fact that Individual #1's poisons do not need to be locked because she is safe around poisons. |
09/27/2023
| Implemented |
| 6400.77(b) | At approximately 12:07PM, the first aid kit did not contain tape. | 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. | A weekly site checklist was created for EIG Management to complete weekly starting the week of 9/18/2023. Management will review any findings with the appropriate direct care staff. Staff also received an updated overview of the information they should review and report daily in relation to the items on this checklist.
Also, a training was sent to all staff on 9/22/2023 alerting the staff of the specific individual items that the first aid kit needs to have inside of it. The staff have been instructed to alert their program supervisor immediately if any of the needed items need to be replaced. |
09/22/2023
| Implemented |
| 6400.216(a) | On 8/31/2023, at approximately 12:09PM, Individual #1's medical binder was in a file holder on top of a locked cabinet in the staff office which is only able to be locked from inside the room. Interviews reveal that the staff office is not always locked because staff are not able to gain entry to the room when the door is locked. | An individual's records shall be kept locked when unattended.
| The door lock has been replaced with an approved keypad lock as outlined in the regulations. Also, the weekly checklist that was created for EIG Management has a specific check to ensure that the Supervisors and the Team Leads are checking weekly that the confidential information is locked up at the sites. |
09/22/2023
| Implemented |
| 6400.163(e) | Individual #1 is prescribed an Epinephrine Injection, USP Single-Dose Auto Injector as needed for bee sting allergy and Albuterol AER HFA Inhaler as needed for wheezing. At approximately 11:50AM, Individual #1 was out in the community with staff and the medications were locked in Individual #1's home. | Epinephrine and epinephrine auto-injectors shall be stored safely and kept easily accessible at all times. The epinephrine and epinephrine auto-injectors shall be easily accessible to the individual if the epinephrine is self-administered or to the staff person who is with the individual if a staff person will administer the epinephrine. | On 9/18/2023 the Operations Manager sent out a training on Therap that all individuals who have an Epi Pen, or an Inhaler or both as a PRN medication, need to take these medications with them EVERY TIME they leave their house. The Operations Manager purchased locked medication bags for each of the individuals at EIG who have these medications. The Operations Manager also posted instructions at each of these houses to take these medications with them when they leave the house. |
09/18/2023
| Implemented |
| 6400.166(b) | On 8/31/2023, at approximately 11:49AM, Individual #1's August 2023 Medication Administration Record was initialed by Direct Service Worker #1 documenting the administration of Doxycycline Mono 100mg capsule for 8/31/2023 at 8:00PM. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The staff were sent a training on Therap on 9/18/2023 specifying that they have to use the Therap App to document and not the laptop version. Each med pass on the App is broken down by administration time and medication time which lessens the chance for a documentation error. |
09/18/2023
| Implemented |
| 6400.182(c) | Individual #1's Individual plan, updated 8/15/2023, reads "Sharp items have been removed from the home so they cannot be used as a weapon." Individual #1's assessment, completed 6/20/23 states that Individual #1 understands knives and sharps, safely avoids, and does not utilize sharp objects independently. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | An email was sent on 8/31/2023 to reflect the fact that Individual #1's sharps were only locked for a small period of time when she slashed the agency vehicle¿s tires. The team feels that she is now safe around sharp objects This individual has not had another incident involving a knife and we do not feel that sharps need to be locked up at this time. This individual also likes to cook and utilizes the knives for cooking. |
09/27/2023
| Implemented |