| 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 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 6400.15a, the Dr. of Program and Services will complete the self-assessment between 3 to 6 months of the license expiration date and according to the written regulations. |
11/07/2022
| Implemented |
| 6400.103 | 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. |
11/07/2022
| Implemented |
| 6400.141(c)(13) | The allergies and contraindicated medications section of Individual #1's 2/20/22 physical examination was left blank. | The physical examination shall include: Allergies or contraindicated medications. | As a result of 6400.141(c)(13), the RPD provided a training refresher to supervisors on 11/2/22, the training covered appointment preparation and proper completion of medical forms. The training form was emailed to licensing on 11/7/22. |
11/07/2022
| Implemented |
| 6400.141(c)(15) | The diet recommendations section of Individual #1's 2/20/22 physical examination was left blank. | The physical examination shall include:Special instructions for the individual's diet. | As a result of 6400.141(c)(13), the RPD provided a training refresher to supervisors on 11/2/22, the training covered appointment preparation and proper completion of medical forms. |
11/07/2022
| Implemented |
| 6400.144 | At Individual #1's 7/22/22 examination, the doctor indicated that if Individual #1's oxygen level dropped below 85% consistently, then the doctor was to be notified. AIMED confirmed that there is no record of Individual #1's oxygen level being tracked. | 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.
| The Dr. did not give the instructions to the staff at the time of the appointment. It was not documented in the visit summary.
As a result of 6400.144, the Dr. was contacted for instructions and/or directions for monitoring Individual #1's oxygen levels. The doctor provided instructions (see attached) |
11/07/2022
| Implemented |
| 6400.145(1) | The emergency medical plan for Individual #1 does 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. | As a result of 6400.145(1), the CEO has revised the Behavioral and Medical Emergency Plan to include the hospital and transportation used. A copy of the revised policy was emailed to licensing on 11/7/22. |
11/07/2022
| Implemented |
| 6400.145(2) | The emergency medical plan for Individual #1 does 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. A copy of the plan was emailed to licensing on 11/7/22. |
11/07/2022
| Implemented |
| 6400.181(e)(4) | Individual #1's 7/14/22 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)(4), the CEO made revisions to the assessment on 10/24/22, to include a separate category for supervision that is easily identifiable. The revised form was emailed to licensing on 11/7/22. The Dr. of Training and Compliance provided a refresher training on 10/21/22 via Zoom to review forms and proper completion with the RPD. A copy of the training form was emailed to licensing on 11/7/22. |
10/21/2022
| Implemented |
| 6400.165(f) | Individual #1's date of admission is 6/21/22. Individual #1's SEEN plan was not written and put into place until 10/3/22. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | The plan was not completed so that there was time to evaluate the individual in order to write a plan.
As a result of 6400.165(f), A new procedure was established that a SEEN plan will be written within 60 days of admission of a new individual. The clinical Director is responsible to develop the plan. The updated SEEN plan was emailed to licensing on 11/7/22. The SEEN plan was added to the admissions checklist, a revised version was emailed to licensing on 11/7/22. |
11/07/2022
| Implemented |
| 6400.165(g) | Individual #1's date of admission is 6/21/22. As of the 10/19/22 inspection, Individual #1 has not had a quarterly psychotropic medication review. | 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 was placed on the waiting list for the psych dr. the week of admissions. Due to long waiting list, the PCP is prescribing and monitoring the medication.
As a result of 6400.165(g), The PCP is reviewing medications until Individual #1 can get an appointment with their psychiatric Dr. and will monitor the individual within the 90-day guideline unless the doctor states in writing it is not necessary. |
11/07/2022
| Implemented |