Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.112(e) | No overnight fire drills were performed at the program on Davis Ave for a 1 year period, from January 2020 -- January 2021 | A fire drill shall be held during sleeping hours at least every 6 months. | To ensure fire drills are completed, including overnight/sleeping hour drills at least every six months, the house manager will create fire drill schedule and carry it out in each home. The house manager will complete the fire drill documentation and submit it for review to the Program Specialist monthly. |
| Implemented |
6400.112(f) | Exit routes were not documented on the fire drill documentation for all fire drill forms provided. | Alternate exit routes shall be used during fire drills. | To ensure that fire drill documentation is accurate and complete, the house manager will create a fire drill schedule and carry out the fire drills, alternating and documenting exit routes for each home. Fire drill documentation will be submitted monthly to the Program Specialist for review. |
04/01/2021
| Implemented |
6400.141(a) | Most recent physical provided for INDIVIDUAL #1 is dated 9/12/19. This is greater than 4 months past the 12 month requirement. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Most recent physical for individual #1 was dated 9/12/2019. Individual was not able to have a physical during 2020 due to COVID-19. His physical was scheduled as soon as his practitioner began seeing patients in person again. Physical dated 2/19/2021 was emailed for review. |
02/19/2021
| Implemented |
6400.141(c)(14) | Medical information pertinent to diagnosis and treatment incase of an emergency not filled out on the physical dated 7/22/20 for individual #2 | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The physical for individual #2 dated 7/22/2020 did not contain medical information related to her diagnosis and treatment in case of emergency. We have contacted her psychiatrist and primary care physician to provide this information in writing as her diagnoses are primarly psychiatric. Once sent to us, we will forward for review. |
10/04/2021
| Implemented |
6400.142(a) | No dental exam provided for individual #1 at time of inspection. | 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. | No dental exam provided for individual #1 at time of inspection. Individual #1 was not able to see the dentist during 2020 due to COVID-19. Individual #1 had a dental exam on 3/22/21. Documentation was emailed for review. |
03/22/2021
| Implemented |
6400.181(a) | No assessment was provided for individual #2 | 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. | No assessment was provided for individual #2. Assessment was completed on 04/03/2020 and emailed for review. |
02/01/2021
| Implemented |
6400.181(e)(10) | Assessment for individual #1 dated 6/3/20 did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | Assessment for individual #1 did not include a lifetime medical history. Individual #1's lifetime medical history was emailed for review. |
02/01/2021
| Implemented |
6400.217 | Documentation of release of information for individual #1 not provided at time of inspection.
Documentation of release of information for individual #2 not provided at time of inspection. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| Documentation of release of information for individual #1 and 2 was not provided at time of inspection. Individual #2's release of information was emailed for review |
02/01/2021
| Implemented |
6400.31(b) | No evidence of individual rights training provided to individual #1
No evidence of individual rights training provided to individual #2 | The home shall educate, assist and provide the accommodation necessary for the individual to make choices and understand the individual's rights. | Individual rights training documentation was not provided for individuals #1 and #2. Individuals #1 and 2's rights training was emailed for review. |
02/01/2021
| Implemented |
6400.163(a) | There was a bottle of Risperidone prescribed to Individual #1 that indicated on the label that its strength was 1mg. The staff person #1 stated that it was .5 mg and went on to say that the wrong dosage was in the bottle. The Medication Administration Record called for .5, but both label and record did not match. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | A bottle of risperidone prescribed to individual #1 indicated on the label that its strength was 1mg. The staff person #1 stated that it was .5 mg and went on to say that the wrong dosage was in the bottle. The MAR called for .5mg but both label and record did not match. Individual #1 was prescribed 1.5 mg of risperidone in the morning. Because his insurance did not cover the 0.5 mg, the pharmacy sent his dosage in two separate blister packs, and it was listed on the MAR as two separate medications: 1mg and .5 mg. That morning, he was administered 1mg from the blister pack, and the last dose of .5mg from the second blister pack before new meds were delivered that afternoon, which was why there was no .5 mg blister pack for AM medication in his box. No medication was being administered from the bottle of risperidone, and it was removed from his medication box. We consulted with EIM regarding the situation, and they determined no medication error occurred. |
02/01/2021
| Implemented |
6400.163(d) | There were several packets of over the counter medications included in the first aid kit including Diphenhydramine and Aspirin. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | Over-the-counter medications were included in the first aid kit. First aid kits were re-checked and OTC medications (aspirin and diphenhydramine) were removed and disposed of. Photos of first aid kids were emailed for review. |
01/28/2021
| Implemented |
6400.167(a)(3) | Due to the discrepancy of the MAR and the label on the Risperidone 1mg bottle, it was determined that the wrong dosage of the medication was being administered to Individual #1. | Medication errors include the following: Administration of the wrong dose of medication. | Due to the discrepancy between the MAR and the label on the 1mg risperidone bottle, it was determined that the wrong dosage of medication was being administered to individual #1. Individual #1 was prescribed 1.5 mg of risperidone in the morning. Because his insurance did not cover the 0.5 mg, the pharmacy sends his dosages in two separate blister packs, and it is listed on the MAR as two separate medications: 1mg and .5 mg. That morning, he was administered 1mg from the blister pack, and the last dose of .5mg from the second blister pack before new meds were delivered that afternoon, which was why there was no .5 mg blister pack for AM medication in his box. No medication was being administered from the 1mg bottle of risperidone, and it was removed from his medication box. We consulted with EIM regarding the situation, and they determined no medication error occurred. |
02/01/2021
| Implemented |
6400.181(f) | No documentation provided that shows the assessment dated 6/3/20 for individual #1 was sent to the team at least 30 days prior to meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | No documentation provided that shows the assessment dated 6/3/20 for individual #1 was sent to the team at least 30 days prior to meeting. An email with assessment was sent to the team on 4/21/21. The meeting had to be rescheduled several times and eventually occurred on 5/17/21. Copy of email sent to team was emailed for review. |
04/21/2021
| Implemented |
6400.183(b) | No record of attendees provided for individual #1 ISP meeting
No record of attendees provided for individual #2 ISP meeting | At least three members of the individual plan team, in addition to the individual and persons designated by the individual, shall be present at a meeting at which the individual plan is developed or revised. | A record of attendees at Individuals #1 and #2 ISP meetings was not provided. To ensure a record of the minimum number of attendees are present at an individual's ISP meeting, under normal circumstances, a sign-in sheet is completed by all attendees at the meeting. Since 3/2020, all ISP meetings have been held virtually due to the pandemic, and no physical sign-in sheet with signatures was created. SCs have emailed sign-in sheets with record of attendees, but no signatures. Once ISP meetings are held in-person again, sign-in sheets will contain signatures. Copies of ISP sign-in sheets will be emailed for review |
01/31/2021
| Implemented |
6400.213(7) | ISP Documentation not provided at the time of inspection for individual #1 | Each individual's record must include the following information: Individual plan documents as required by this chapter. | ISP documentation was not provided at time of inspection for individual #1. ISP invite letter and sign-in sheet emailed for review. Please note virtual annual ISP meeting took place 4/21/21, after inspection. |
03/15/2021
| Implemented |