| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency license expiration date is 11/30/22. The self-assessment for this home was completed 9/16/22 through 9/29/22, outside of the window required by regulation. | 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.
| There was some confusion around the time frame stated on the notice and the regulation.
As a result of 6400.15(a), the Dr. of Program and Services will place the due date on the shared calendar and complete the self-assessment between 3 to 6 months of the license expiration date and according to the written regulations. |
11/07/2022
| Implemented |
| 6400.81(k)(6) | At the time of the 10/18/22 inspection, Individual #1's bedroom did not have a mirror. | In bedrooms, each individual shall have the following: A mirror. | The mirror was removed due to the health and safety of the individual and the mirror had to be replaced.
As a result of 6400.81(k)(6), the Operations Manager purchased a plexiglass mirror on 10/18/22. The mirror was hung on the wall on 10/27/22. Picture of mirror on the wall was emailed to licensing 11/7/22 |
10/27/2022
| Implemented |
| 6400.103 | The emergency evacuation plan for the home does not include individual responsibilities, means of transportation, or an emergency shelter location. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| As a result of 6400.103, the CEO revised the emergency evacuation plan on 10/24/22, to clearly outline on-shift staff responsibilities, shelter location and transportation expectations. Revised version emailed to licensing on 11/7/22. |
10/24/2022
| Implemented |
| 6400.106 | Individual #1 moved into the home on 4/25/22. The furnace was not inspected in this home until 5/11/22. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| As a result of 6400.106, the CEO or Dr. Prog and Serv shall ensure that each home has a current furnace inspection. The Dr. of Training and Compliance shall ensure that the Operations Manager has the furnace inspected prior to a new move-in and the RPD will provide a second check. The site preparation checklist has been updated to include "furnace inspection," |
11/07/2022
| Implemented |
| 6400.144 | Individual #1 had a new patient appointment with their PCP on 12/16/21. The physician wanted a 2-month follow-up for this visit. This follow up appointment was not completed. | 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.
| There was a change in staff & management, and the information was not communicated from previous staff.
As a result of 6400.144, the Program Specialist will ensure that all appt follow-ups are placed on the calendar and shared with the RPD. The portal login information is now shared on the drive for others to access. The RPD provided a refresher training to the Residential Supervisors on 11/2/22. |
11/02/2022
| Implemented |
| 6400.145(1) | The emergency medical plan for Individual #1 did not include a hospital or source of health care to be used in an emergency. | The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. | The correct Behavioral and Medical Emergency policy wasn't used for the annual licensing and has since been replaced with the correct form.
As a result of 6400.145(1), the CEO has revised the Behavioral and Medical Emergency Plan to include the hospital and transportation used. The revised version was emailed to licensing on 11/7/22. |
11/07/2022
| Implemented |
| 6400.145(2) | The emergency medical plan for Individual #1 did not include a means of transportation. | The home shall have a written emergency medical plan listing the following: The method of transportation to be used. | The correct Behavioral and Medical Emergency policy wasn't used for the annual licensing and has since been replaced with the correct form.
As a result of 6400.145(1), the CEO has revised the Behavioral and Medical Emergency Plan to include the hospital and transportation used. Revised version was emailed to licensing on 11/7/22. |
11/07/2022
| Implemented |
| 6400.181(e)(4) | Individual #1's 2/9/22 assessment does not include their current level of supervision. | The assessment must include the following information: The individual's need for supervision.
| The level of supervision is within the body of the assessment and but not easily identified as a separate category.
As a result of 6400.181(e), the CEO made revisions to the assessment on 10/24/22, to include a separate category for supervision that is easily identifiable. The revised assessment was emailed to licensing 11/7/22. |
11/07/2022
| Implemented |
| 6400.165(b) | Individual #1's physician increased their Risperidone dosage from 1.5mg twice daily to 2mg twice daily on 9/12/22. Individual #1 did not receive the increased dosage in the home until 9/22/22. | A prescription order shall be kept current. | The delivery of the medication had a two day delay due to delivery attempts and no one was home. There was a miscommunication between staff and the Dr. during the virtual appointment. When medications were received, the staff was not clear on the change and needed to confirm med change with the Dr. The change was not done until it was confirmed with Dr. There was a gap in between the time the staff contacted the Dr. and when they returned the call.
As a result of 165(b), The RPD provided a refresher training on 11/2/2022, to review proper protocol for after appt visits. The staff will give the summary to the Program Specialist immediately after the appointment. |
11/02/2022
| Implemented |
| 6400.165(g) | Individual #1's 6/3/22, 7/8/22, and 9/12/22 medication reviews do not include the reason for prescribing the medication. | 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 outdated psychiatric form was being used by the residential supervisor, the form was missing the current medications, which are completed by the staff prior to the appointment.
As a result of 6400.165(g), The correct form was sent to the Program Specialist on 10/21/22 and Residential Supervisor was to begin using the current form. The RPD provided a refresher training with the residential supervisor to review proper form completion and protocol on 11/2/22. |
11/02/2022
| Implemented |
| 6400.166(a)(2) | At the time of the 10/18/22 inspection, the October 2022 Medication Administration Record (MAR) did not include the name of the prescriber for all of the medications. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | The pharmacy that is being used, put the name of the prescriber on the bottom of MAR and did not include all prescribers' names.
As a result of 6400(a)(2), The CEO had the RPD contact the pharmacy on 10/18/22 and instructed them to put the prescriber name in each medication row. The pharmacy complied and a copy of the MAR was emailed to licensing on 11/7/22. |
11/07/2022
| Implemented |
| 6400.167(a)(1) | Individual #1 did not receive their 8pm dose of Risperidone on 3/31/22. | Medication errors include the following: Failure to administer a medication. | Medication blister packs were reviewed at the end of the month and all medications had been given. There was a documentation error.
As a result of 6400.167(a)(1), the RPD provided refresher training to the Residential Supervisor on 11/2/22. The RPD is responsible to ensure that the Residential Supervisor reviews the MAR daily and reports any error. A copy of the training form was emailed to licensing on 11/7/22. |
11/02/2022
| Implemented |
| 6400.167(b) | Individual #1's failure to receive their 8pm dose of Risperidone on 3/31/22 was not documented as a medication error. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | Medication blister packs were reviewed at the end of the month and all medications had been given. The PS failed to document as a documentation error on the MAR
As a result of 6400.167(b), the RPD provided refresher training with Residential Supervisor on 11/2/22. The RPD is responsible to ensure that the Residential Supervisor reviews the MAR daily and reports any error. |
11/02/2022
| Implemented |