| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(e)(3) | Individual #1's June ledger did not list a receipt for Amazon on June 20th 2018 for two purchases Dryel $17.11, and 1000 Vinyl gloves $33.99-totalling $54.17. Individual #1's June ledger shows an expense of $16.48 no record of receipt found. | 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. | The CEO adjusted the june ledger to include the Amazon purchase on June 20th 2018 forDryel $17.11 and 1000 vinyl gloves $33.99 totalling $54.17. The receipt for the expense of $16.48 could not be found so the expense was removed from the record and refunded. to avoid future occurences, the CFO will document all purchases and receipts for individual #1. |
12/19/2018
| Implemented |
| 6400.46(c) | Staff member #2 did not complete 24 hours of annual training relevant to human services or administration. | The chief executive officer shall have at least 24 hours of training relevant to human services or administration annually. | Staff member #2 completed the required training prior to the inspection, but the training was not documented. To prevent a reoccurrence, the CEO will document each training of staff member #2 as soon as any training is completed. |
12/05/2018
| Implemented |
| 6400.64(f) | There were two trash bags left in the basement area, not in closed receptacles | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | The two trash bags were placed in the empty trash bin that was nearby shortly after the inspection.
Lead staff has been trained to check outside the residence each week to ensure that no trash bag is left outside the trash bin. |
12/04/2018
| Implemented |
| 6400.68(b) | The hot water in the bathtub was 127.9 degrees Fahrenheit. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The hot water temperature in the bathtub has been reduced to 120 degrees F. To avoid a reoccurrence, the lead staff will be trained how to check the water temperature and report findings to the CEO who will make any necessary adjustment to the water temperature. A monthly record of water temperature will be maintained at the residence. |
12/10/2018
| Implemented |
| 6400.72(b) | In the master bedroom the window on the left had a crack approximately 12inches in length. | Screens, windows and doors shall be in good repair. | This window in the master bedroom was recently installed as were all the other windows throughout the home. The master bedroom has always been unoccupied, so staff was aware of the crack. The cracked window has been replaced. To prevent this incident from reoccurring, the lead staff has been trained to inspect all windows at the end of each month and report findings to the CEO. |
01/10/2019
| Implemented |
| 6400.110(e) | The smoke detectors were not interconnected throughout the home. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | New smoke detectors that are interconnected have been bought and are being installed. CEO will avoid this from happening again by reading the governing regulations and complying. |
03/15/2019
| Implemented |
| 6400.111(f) | The Fire extinguishers throughout the home were not inspected. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | The fire extinguishers have been inspected. To avoid a reoccurrence, CEO will train lead staff to check fire extinguishers at the end of each month to find out which fire extinguishers need inspection and to inform CEO of her findings. |
12/31/2018
| Implemented |
| 6400.113(a) | Individual #1's record did not have documentation of fire safety training. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | The fire safety training record was not filed in the individual's program binder therefore it was not seen by the inspector. To prevent this from happening again, CEO will train lead staff on the proper filing of this document. |
12/05/2018
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination dated 5/19/18 did not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination form was amended by the doctor. To avoid a reoccurrence, staff will be trained to examine this form for completeness before leaving the doctor's office, |
01/08/2019
| Implemented |
| 6400.167(b) | Individual #1's Calcium +D3 600-200mg unit tabs take 2 tablets by mouth everyday is on the label, but the MAR does not indicate when and how much should be taken. | Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. | The MAR has been adjusted to reflect two tablets will be taken at the same time daily. To avoid a reoccurrence, CEO will ask the doctor to be more specific about frequency and dose of prescribed medication in order to eliminate any ambiguity. |
12/11/2019
| Implemented |
| 6400.168(d) | Staff person #1 did not complete an annual medication administration practicum training, but administered medications. | A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. | Staff person #1 has completed the annual medication practicum. To avoid this from happening again, CEO will check training records at the end of each month to determine if annual practicum training is due. |
01/02/2019
| Implemented |
| 6400.181(d) | The Program Specialist did not sign or date the assessment. | The program specialist shall sign and date the assessment. | The assessment has been signed and dated by the Program Specialist. To avoid this mistake from occurring again, CEO will show Program Specialist where the document must be signed and dated and also check for completeness |
12/05/2018
| Implemented |
| 6400.181(e)(5) | Individual #1's assessment did not include if they had the ability to self-administer medications. | The assessment must include the following information: The individual's ability to self-administer medications. | The incorrect assessment was inspected. The assessment that contained this information was placed in the wrong binder. To avoid a reoccrrence of this incident, CEO will train the program specialist on the proper filing of assessments. The CEO will also check program binder at the end of each month for completeness. |
12/05/2018
| Implemented |
| 6400.181(e)(6) | Individual #1's assessment did not include if they had the ability to safely use or avoid poisonous materials. | The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | The assessment now contains this information. It is available. In the future, management will ensure that all required information is contained in the assessment. |
12/05/2018
| Implemented |
| 6400.181(e)(7) | Individual #1's assessment did not include if they have knowledge of heat sources and can move away. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | The assessment has been completed to reflect the individual's knowledge of danger of heat source. Management will ensure thgat all assessments done in the future reflect this information by checking the regulations. |
12/04/2018
| Implemented |
| 6400.181(e)(14) | Individual #1's assessment did not include if they have knowledge of water safety and the ability to swim. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | This information was recorded in the assessment that was not seen by the inspector because the assessment was not in the program binder. To avoid a reoccurrence, the CEO will check the program binber at thwec end of each month to ensure that theassessment is correctly filed. |
12/05/2018
| Implemented |
| 6400.186(a) | The program specialist did not complete an ISP review with individual #1 every 3 months as required. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. | The program specialist has completed the missing ISP reviews. To avoid a reoccurence of this incident, the CEO will conduct an audit at the end of each month to identify any missing ISP reviews. If revies are missing, the program specialist will be advised to have those reviews done. |
01/03/2019
| Implemented |
| 6400.217 | Individual#1's record did not include a written consent for release of information. | 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.
| The consent form was completed before the inspection, but it was placed in the wrong binder. To avoid a reoccurence, the CEO will check the program binder at the end of each month to ensure that this form is in the binder. |
12/05/2019
| Implemented |