| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | It could not be determined if individual's #1 funds were used for their benefit, as documentation for each single purchase exceeding $15 made for or by individual #1 was not provided by the agency. | Individual funds and property shall be used for the individual's benefit. | Receipts for purchases over $15 were not provided at the time of inspection. Copies of individual #1¿s receipts to be emailed to licensing for review. (attachment_NC_receipts). |
03/31/2022
| Implemented |
| 6400.22(e)(3) | Documentation needed for actual receipt or expense for each single purchase exceeding $15 made for or by individul #1 was not provided by the agency. [REPEATED NON-COMPLIANCE 1/26/21] | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | Receipts and/or documentation for purchases over $15 were not provided at the time of inspection. Copies of individual #1¿s receipts to be emailed to licensing for review. (attachment:_NC_receipts). |
03/31/2022
| Implemented |
| 6400.64(a) | The bathroom shower adjoining Individual #1 bedroom has a substance consistent with mildew around the perimeter. This should be cleaned and recaulked. | Clean and sanitary conditions shall be maintained in the home. | Individual #1¿s bathroom shower was not properly clean at the time of inspection. CEO directed staff on second shift on 2/22/22 to clean entire bathroom, including shower. Photo of bathroom to be emailed to licensing for review (attachment: Cricket_shower) |
03/31/2022
| Implemented |
| 6400.66 | The side exit and back exit exterior lights are inoperable. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The exterior lights at the side and back doors were not working at time of inspection. Light bulbs were replaced, and photos showing operable lights to be emailed to licensing for review. (attachment: Elm_lights) |
03/31/2022
| Implemented |
| 6400.76(a) | The dining room chairs have rips and should be repaired or replaced. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Dining room chairs were in need of repair/replacement at the time of inspection. Chairs had been ordered but had not been delivered at the of inspection. Invoice/receipt emailed to licensing for review (attachment Elm_chair_invoice). Chairs were delivered on 2/24/22 and photo to be emailed to licensing for review. (attachment Elm_chairs) |
03/31/2022
| Implemented |
| 6400.111(a) | The attic did not contain a fire extinguisher. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | There was no fire extinguisher in the attic as required at the time of inspection. Provider purchased a fire extinguisher and placed it in the attic on 2/26/22. Photo of fire extinguisher in attic to be emailed to licensing for review (attachment: Elm_attic_fire_ext) |
03/31/2022
| Implemented |
| 6400.112(c) | A written record is to be kept for all fire drills; the form used by the agency for Elm Ave. did not mention the exit route used on 1/11/21. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | For the fire drill of Jan 2021, the exit route was not indicated on the fire drill reporting form. This form was revised in February 2021 to include the exit route. All blank fire drill forms have been removed from circulation and a new form, revised 2/2022, has been put into use moving forward (attachment NEW_FIRE_DRILL_FORM_0222) starting with March 2022 Fire Drill. |
03/31/2022
| Implemented |
| 6400.112(e) | A fire drill was not held during sleeping hours at least every 6 months for Elm Ave. [REPEATED NON-COMPLIANCE 1/26/21] | A fire drill shall be held during sleeping hours at least every 6 months. | Overnight fire drills were not conducted during required periods of at least every six months during the review period (2021). An overnight fire drill will be conducted during March 2022 (attachment: Elm_fire_drill0322) |
03/31/2022
| Implemented |
| 6400.141(a) | It could not be determined if individual #1 has had a physical completed annually. Agency did not provide verification of previous physical. [REPEATED NON-COMPLIANCE 1/26/21] | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #1¿s previous year (2020) physical was not available at the time of inspection to verify that individual had an annual physical. Individual #1 did not have an in-person annual physical in 2020, yet had a telehealth visit on 4/17/2020. COO requested copy of office notes from the telehealth. Once received, they will be emailed to licensing for review. 2022 annual physical exam is due in June. PCP is not yet scheduling that far out. Will be scheduled at the end of April. (attachment NC_telehealth_physical2020) |
03/31/2022
| Implemented |
| 6400.141(b) | Individual #1 6/18/21 Physical Examination form was not dated by the physician. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Individual #1¿s annual physical exam was not dated by the physician. House Manager will contact physician for documentation verifying individual was seen on 6/8/21. |
03/31/2022
| Implemented |
| 6400.141(c)(4) | Individual #1 6/8/21 physical examination was blank in the hearing screening section. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Individual #1¿s hearing screening section was left blank on her 6/8/21 physical exam. House Manager will contact physician to determine if hearing test was recommended and, if so, done at last health assessment. |
03/31/2022
| Implemented |
| 6400.141(c)(6) | It could not be determined if or when Individual #1 had their last Tuberculin (TB) skin testing with negative results, as on the 6/18/21 physical form, the TB portion was omitted and provided failed to provide any other verification when asked. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | The TB section of individual #1¿s last physical form was incomplete. The House Manager will contact physician to determine if TB test was completed at last health assessment. If so, House Manager will obtain documentation of TB test for submission to licensing. If not, TB test will be scheduled for individual #1 and results sent to licensing for review (attachment: NC_TB) |
03/31/2022
| Implemented |
| 6400.141(c)(7) | Individual #1 last gynecological exam was completed on 3/15/17. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Individual #1 did not have documentation of a gynecological exam for 2021 in their file. Documentation for individual¿s gynecological exam was not able to be located. House Manager contacted individual¿s gyn provider and requested evidence of the most recent gyn exam and the past gyn exam. Individual #1 saw her gyn for an annual well woman visit on 7/1/21, 11/26/19 and 8/15/18. She did not see her gyn in person during 2020 due to the COVID pandemic. House Manager requested office notes from the gyn visit as evidence she saw the gyn. Once documentation is received, it will be emailed to licensing for review, and placed in individual¿s file. |
03/31/2022
| Implemented |
| 6400.141(c)(10) | The communicable disease portion on the physical exam dated 06/08/2021 for individual #1 was left blank. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | The communicable disease section of individual #1¿s last physical exam (6/8/21) House Manager will contact physician to determine status of communicable diseases for individual #1 at the time of last health assessment. |
03/31/2022
| Implemented |
| 6400.141(c)(14) | Info pertinent to diagnosis in case of emergency was not filled out on individual #1 physical exam dated 06/08/2021. [REPEATED NON-COMPLIANCE 1/26/21] | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Individual #1¿s health assessment was missing emergency information relating to diagnoses as required. House Manager will contact physician to request information relating to individual #1¿s diagnoses in the event of an emergency and will update individual¿s file (attachment: NC_diagnosis_info_emergency) |
03/31/2022
| Implemented |
| 6400.142(a) | The agency failed to provide Dental examination performed by a licensed dentist annually for individual #1. [REPEATED NON-COMPLIANCE 1/26/21] | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Individual #1¿s documentation of most recent dental exam was not located. Provider has requested after visit summary/office notes from last dental visit. Once documentation is received, COO will email to licensing for review, and placed in individual¿s file. Individual #1's next dental exam appointment is 3/28/2022. |
03/31/2022
| Implemented |
| 6400.144 | Individual #1 prescribed medications fluticasone Nasal Spray 50 MG, Bromfed DM Syrup (PRN), Cetirizine 10 MG (PRN) Tab, Diphenhydramine 25 Cap(PRN), Docusate Sodium 100 MG Tab (PRN), Halls Cough Drop (PRN), Loperamide 2 MGIndividual #1 prescribed medication DIVALPROEX 250mg was not administered on 02/23/2022 as prescribed, the agency was unable to locate the medication. The blister pack was empty, medication is to be administered at 8am and 8pm. Cap (PRN), Mucinex 600 MG Tab (PRN) and Cepacol (PRN) were not present in the home at the time of inspection. | 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.
| Individual #1¿s PRN medications and two prescribed medications were not present in the home at the time of inspection. Med trainer called pharmacy for refills of the medications on 2/24/22. Medications were delivered between 2/28 and 3/7/22. |
03/31/2022
| Implemented |
| 6400.181(a) | The agency failed to provide the annual assessment for Individual #1. [REPEATED NON-COMPLIANCE 1/26/21] | 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. | Assessments for individual #1 was not available as required at the time of inspection. Assessment for individual #1 was obtained from the Program Specialist and emailed to licensing fore review (attachment Aegis_assessments) |
03/31/2022
| Implemented |
| 6400.161(c) | Staff has not provided individual #2 assistive technology or a visual device, (ie; medication administration record) to assist them self-administer medication. | The home shall provide or arrange for assistive technology to assist the individual to self-administer medications. | Individual #2 did not have assistive technology or visual devise to assist with self-administering medication present at the time of inspection. A MAR was created for individual #2 to use in the interim until individual was active in the pharmacy¿s system and an automated MAR was received. (attachment:
Elm_indiv2_MAR) |
03/31/2022
| Implemented |
| 6400.161(e)(3) | Individual #2 has not been provided assistance in Self-Administering medication. Staff is not observing individual, as they are taking medication ARIPIPRAZOLE 15mg in the morning, despite this medication having prescribing instructions to be taken at bedtime. | To be considered able to self-administer medications, an individual shall do all of the following: Know when the medication is to be taken. Assistance may be provided by staff persons to remind the individual of the schedule and to offer the medication at the prescribed times as specified in subsection (b). | Individual #2 was not receiving appropriate assistance to self-administer medication at the time of inspection. Medication Trainer met with individual #2 on 2/24/22 to discuss how they had been taking their medication while living at home, and to explain how taking medication in a CLA was different. Medication Trainer contacted individual #2¿s physician¿s office to clarify medication instructions, as medication bottles instructed one thing, and individual said they had been taking them differently (while living at home). It was not clear how individual was taking their medications prior to intake at Aegis. Physician¿s office said it did not matter as long as they were taken at the same time every day. Mediation Trainer explained to physician¿s office, that medication in a CLA had to be taken exactly as the prescription and medication labels indicated, and that instructions must be clear and not open to interpretation (i.e a specific time rather than ¿once daily¿ or even "before breakfast" or "bedtime" as those times could vary by hours from day to day. Medication Trainer requested new prescriptions with explicit, concrete instructions for all medication to be sent to provider¿s pharmacy. New medications have not yet been processed and delivered at this time. Once received, copies of new instructions will be emailed to licensing for review (attachment Elm-indiv2_Rx). |
03/31/2022
| Implemented |
| 6400.166(a)(4) | Individual #1 prescribed medication, Vitafusion Multivitamin Gummies are listed on the MAR but Flintstone Gummies were present at the time of inspection. The name of the medication should match the prescription or the medication record should offer an explanation as to why an alternate medication is being administered. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | Individual #1¿s prescribed vitamins present at the time of inspection did not match the MAR. Medication Trainer called the pharmacy on 2/24/22 and asked why different vitamins had been sent. Pharmacy stated that physician prescribed new vitamins, but did not discontinue former vitamins. Medication Trainer asked pharmacy to contact physician for a discontinuation order and correct MAR with current vitamins. (attachment: Elm_indiv1_vitamins) |
03/31/2022
| Implemented |