| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | At the time of inspection there was only one operational light bulb in the basement. The other bulbs present were not operational. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| At the time of inspection, the lighting in the basement was not sufficient, as there was only one light bulb working. Light bulbs were replaced in all light sockets in the basement on 2/24/22 (attachment: Church_basement_lights) |
03/31/2022
| Implemented |
| 6400.72(a) | The window in the main bathroom does not have a screen. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | At the time of inspection, the master bathroom did not have a screen on its window so that the window could be opened for ventilation, nor did it have a fan for ventilation. President contacted a contractor to advise on installing a fan or screen on the window. Contractor said that type of window could not support a screen because of the way it opens and closes and suggested replacing the window. President ordered a new window on 2/25/22 (attachment: Church_window_invoice). Estimated delivery date is 2-3 weeks. Once window is installed, provider will email a photo of window and screen to licensing for review. (attachment: Church_bathroom_window) |
03/31/2022
| Implemented |
| 6400.141(c)(7) | Individual # 1 physical did not include a gynecological examination. | 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 has a documented history of refusing gynecological exams and colonoscopies. Primary care physician has carried out breast exams and individual #1 has conceded to mammograms in the past. Provider will continue to stress the importance of gynecological exams in safeguarding her overall health and to encourage individual #1 to see the gynecologist. To date, there is no recent gyn exam for individual #1. |
03/12/2022
| Implemented |
| 6400.144 | Individual #3 prescribed medication CHLORPROMAZ 50mg and HEARTBURN 20mg was administered all month up to 02/22/2022, the medication was discontinued and not administered on 02/23/2022. Changes in medication must be made in writing by the prescriber, it could not be determined if this medication was given to the individual during the month of February.
Individual #1 did not have the following prescribed medications in the home at the time of inspection:
Artificial Tears 1.4% Solution, Liquid Acetaminophen 160 MG PRN, Geri-Lanta PRN, Maxalt 10 MG Tab PRN, Eucerin Cream PRN, Proventil/Ventolin PRN. | 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 PRN medications were not in the home at the time of inspection. Med trainer contacted the pharmacy for refills of PRNs on 2/24/22 and they were delivered between 2/28 and 3/7/22. Individual #3¿s medications chlorpromazine 50 mg and heartburn 20 mg were discontinued by her physicians. Copies of the discontinuation orders to be sent to licensing for review. |
03/31/2022
| Implemented |
| 6400.181(a) | Individual # 1 has not had a required assessment completed. [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 for review (attachment: Aegis_assessments) |
03/31/2022
| Implemented |
| 6400.15(b) | Aegis did not use the most current licensing inspection instrument for their self-assessments. They used a document from 2019, which has regulations that are no longer in use and does not include new regulations which has been added since then. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | Provider used outdated licensing inspection instrument (2019) for its self-assessment so compliance was not accurate as some regulations had changed with the newest self-inspection tool. Lead inspector offered to email a copy of the most recent self-inspection tool to provider, and provider received it on 2/22/22. Provider also asked lead inspector if they should re-do the self-inspection on the current tool, and was told they would not need to. |
03/31/2022
| Implemented |
| 6400.165(c) | Individual #1 prescribed medication CARB/LEVO ER 50-200 MG Tab, with instructions to be taken only at 11 PM, is being administered in the morning and at 11pm. | A prescription medication shall be administered as prescribed. | The MAR for individual #1¿s medication, carb/levo ER 50-200mg tablet, reflects being given both in the morning and at 11pm when instructions state to give it at 11 pm. Med trainer spoke with staff who signed the MAR in the morning to confirm whether or not it was given in the morning.
Staff all stated it was not given. Med trainer reviewed MAR documentation with all staff on 2/24/22, and will conduct a formal training at the post-inspection training and individually through April. |
03/31/2022
| Implemented |
| 6400.165(g) | Individual # 1, whom was admitted on 9-15-21, has not had the required quarterly psychotropic medication review, even though they are prescribed at least one psychotropic 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. | Individual #1 did not have a quarterly psychotropic medication review as needed. Individual #1 was scheduled for a virtual visit with their psychiatrist on 2/22/22. A psychotropic medication review was sent to the psychiatrist for completion after the appointment. Once review has been received it will be emailed to licensing for review (attachment: NB_psych_med_review). |
03/31/2022
| Implemented |
| 6400.166(a)(10) | Individual #1 prescribed medication CARB/LEVO ER 50-200 MG Tab, with instructions to be taken only at 11 PM, is being administered at an unidentified time in the morning and at 11pm. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | The MAR for individual #1¿s medication, carb/levo ER 50-200mg tablet, reflects being given both in the morning and at 11pm when instructions state to give it at 11 pm. Med trainer spoke with staff who signed the MAR in the morning to confirm whether or not it was given in the morning.
Staff all stated it was not given. Med trainer reviewed MAR documentation with all staff on 2/24/22, and will conduct a formal training at the post-inspection training and individually through April. |
03/31/2022
| Implemented |
| 6400.166(a)(13) | The medication recorded (MAR) is not being kept current when medication is administered. Individual #2 prescribed medication, ENSURE ENLIVE .08gram, was not initialed by the staff giving the medication.
Individual #3 prescribed medication RISPERIDONE 4mg was not initialed by the staff giving the medication on the medication administrative record (MAR) on 02/14/2022. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | The MAR for individual #2 and #3 is not being kept current when medication is administered as required. Med trainer checked with staff giving the Ensure Enlive, and they stated individual#2 frequently refuses the Ensure Enlive. Med trainer reviewed the documentation protocol for refusals. Med trainer checked with staff who administered meds on 2/14/2022 for individual #3 and they were administered. Med trainer reviewed documentation protocol with staff. Med trainer reviewed the documentation process with the staff, and will conduct a formal training at the post-inspection training and individually through April. |
03/31/2022
| Implemented |
| 6400.166(b) | Individual #1 prescribed medication, Chlorodex .12% Solution (Medicated Mouthwash), hydrocortisone cream 2.5% and petroleum jelly are to be administered at 8 AM and 8 PM daily but has not been initialed as given at 8 PM from February 1, 2022 through the night before the inspection on February 21, 2022.
Individual #1 prescribed medication, Artificial Tears 1.4% Solution (which was not present at the time of inspection) was signed off as administered for future times of 4 pm and 8 pm on 2/22/22. The licensing rep observed this at 1 pm on 2/22/22. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Individual #1 prescribed medications Chlorhexadine Gluconate .12% Solution, hydrocortisone cream 2.5% and petroleum jelly are to be given at 8am and 8pm daily but were not documented on the MAR for 8pm. Individual #1¿s artificial tears 1.4% was signed for 4pm and 8pm on 2/22/22 prior to the time of scheduled administration, not following recording at the time of administration. Med trainer reviewed documentation with the staff who signed for the medications, reinforcing that medication cannot be signed for before or after the time of administration. |
03/31/2022
| Implemented |
| 6400.167(a)(4) | Individual #1 prescribed medication, Ammonium Lac Cream 12%, with instructions to be applied at bedtime is being administered at 8 AM daily. [REPEATED NON-COMPLIANCE 1/26/21] | Medication errors include the following: Failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time. | Med trainer contacted individual¿s doctor to ask about the two different prescriptions for the same medication, made at different times. One prescription said to apply daily, the newer prescription specified every night at bedtime. The pharmacy assumed ¿daily¿ to be 8:00am, however the medication was only intended to be applied once a day, not two. These were supposed to be one prescription entry on the MAR, and one of them should have been discontinued when the second physician renewed the prescription with different wording. Med trainer spoke with staff about the two MAR entries and following instructions on the MAR and medication label, and the necessity of asking for clarification if there is confusion. Both medications were discontinued at individual #1¿s next appointment on 3/7/22. |
03/31/2022
| Implemented |
| 6400.181(f) | It cannot be determined if individual #1 plan team received a copy of the assessment, as it cannot be determined if an assessment was completed. [REPEATED NON-COMPLIANCE 1/26/21] | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | It was undetermined whether individual #1¿s plan team received a copy of the initial assessment, which must be provided within 30 days prior to an ISP meeting. ISP meeting was held 1/7/21. Individual #1's initial assessment was completed on 11/15/21. The plan team did not receive a copy of the assessment prior to the 1/7/22 meeting, as the Program Specialist was on a leave of absence and had not provided anyone with the assessment to be forwarded in his absence. CEO has sent the initial assessment to the team. |
03/31/2022
| Implemented |
| 6400.182(b) | Individual #1 did not have an ISP completed within 90 days of their 9-15-21 admission date. The ISP was completed on 1-7-22. | The initial individual plan shall be developed based on the individual assessment within 90 days of the individual's date of admission to the home. | Individual #1 did not have an ISP completed within 90 day of their 9/15/21 admission date. The ISP was completed on 1/7/22. Individual #1 had a team meeting on 10/19/21, 12/30/21, and 2/1/22. At the 90 day mark, individual #1 was being assigned a new Support Coordinator. The meeting was held once that new SC was on board. |
03/31/2022
| Implemented |