| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | There was a closet next to the bathroom which was not locked. Inside that closet was both individual hygiene supplies as well as household cleaners. These cleaners included ajax bleach, Clorox spray, and Windex. There was also laundry detergent in this closet. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The CEO met with the House Managers¿ Supervisor on 9/5/2022 and asked that the house managers review safety concerns with the attending staff members and to emphasize the importance of following safety procedures as well as the company¿s policies and procedures. All staff is responsible to ensure that all cleaning agents and personal care supplies are always locked away. Staff who fails to comply to their responsibility will be held accountable. |
09/05/2022
| Implemented |
| 6400.142(f) | Individual #2 did not have any documentation that reflects the individual has a dental hygiene plan in place. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | A dental hygiene plan was written for all the individuals in our care. The plan was read and explained in simple terms to all the individuals and signed by individuals and staff. |
09/28/2022
| Implemented |
| 6400.143(a) | Individual #2 had a gynecologist appointment on 9/23/2021 at which time the individual refused, it was stated that the individual did not need a pap smear until 2022. Individual #1 refused the gynecologist apt on 7/14/2022 as well. CEO did provide a letter dated 8.30.22 that stated Individual #2 would be trained, however no previous training was provided or documented for the refusals. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | An informed Refusal Form will now be used to document all routine medical or dental examinations that is being refused by an individual. Medical or dental procedures will be explained to individuals ahead of each respective appointment |
09/28/2022
| Implemented |
| 6400.144 | Individual #2 had a dental exam on 9/16/2021. The follow up treatment was set to come back in 6 months. The recommendations on this exam reflects that individual should have dental cleanings every 3 months. The following appointment was not until 3/16/22. The service was not provided as per the dentist recommendation of having cleanings every 3 months. | 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 Program Specialist will review all paperwork from respective doctor¿s appointment within 24 hours and question any information that seems out of the ordinary. For example, the dental form in question, the follow up dental work needed stated 6 months recall yet under recommendations the dental hygienist recommended every 3 months for cleaning. The Program Specialist called to schedule appointment and was informed that the individual does not need to see the dentist before the routine time of March 2022. |
09/30/2022
| Implemented |
| 6400.32(r)(1) | Individual #2 had a bedroom door lock. At the time of inspection, the individual was asked if the individual had a key to the bedroom door, at which time individual stated no. I asked the individual if the individual wanted a key to the individual's bedroom door and the individual said yes. The staff did have a key, however the individual did not have a key to open the individuals bedroom door.
The ISP said that individual was asked if the individual wanted a key to the front door and or bedroom door. The ISP reflects that the individual said no at that time. | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | A key was given to individual #2 for the bedroom. |
08/31/2022
| Implemented |
| 6400.46(a) | Staff #4 did not have documentation to reflect that She had fire safety during his orientation and prior to working with individuals.
There was a follow up document that reflects Staff #4 had a training, however the training was not dated. | Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | The initial fire safety training form for new employees was modified to include date training was conducted. |
09/30/2022
| Implemented |
| 6400.163(h) | Individual #2 had a cream for psoriasis by the name of Triamcinolone. This cream is to be used every morning. This cream was dispensed on 5/14/2021 and it was to expire on 5/14/2022. This cream was still in the medicine box and shall be disposed as it is expired.
Individual #2 had Debrox ear drops that were to be used for 7 days or until follow up with the Dr. The Dr discontinued the ear drops, but the medication remained in the medicine box. This medication should be disposed of properly. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | The Nurse will conduct monthly checks to ensure that all medications in the medication boxes and in storage boxes are current and safely dispose of any expired/discontinued medications the day it becomes expired/discontinued. |
08/30/2022
| Implemented |
| 6400.165(c) | Individual #2 had a cream for psoriasis by the name of Triamcinolone. This cream is to be used every morning. This cream was dispensed on 5/14/2021 and it was to expire on 5/14/2022. There was still cream in this jar on the day of inspection which was 8/30/22. It appears that if the cream was being used as directed, the cream would have been used by the expiration date. There was also 2 refills with the original order. | A prescription medication shall be administered as prescribed. | Medications will be used on a first in first out basis while being cognizant of expiration dates. Will work with the pharmacy to ensure that an oversupply of topical medication does not occur. |
08/30/2022
| Implemented |
| 6400.186 | Individual #2 ISP states that poisons should be locked. At the time of inspection there was a closet full of cleaning supplies and hygiene supplies that was not locked. | The home shall implement the individual plan, including revisions. | All poisonous supplies are kept locked away and out of reach from the individuals. Additionally, The CEO met with the House Managers¿ Supervisor on 9/5/2022 and asked that the house managers review safety concerns with the attending staff members and to emphasize the importance of following safety procedures as well as the company¿s policies and procedures. All staff is responsible to ensure that all cleaning agents and personal care supplies are always locked away. Staff who fails to comply to their responsibility will be held accountable. |
09/05/2022
| Implemented |