| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The 3 to 6 months completion window for the agencies self-assessments prior to the expiration date of the agency's certificate of compliance was 9/26/22 to 12/26/22, and the self- assessment was completed on 1/10/23. This exceeds the requirement. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| Community Resources for Human Services (CRHS) management will ensure self-assessments are completed in each serving home within 3-6 months prior to the expiration date of the certificate of compliance to measure and record compliance. |
03/16/2023
| Implemented |
| 6400.141(a) | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Individual #2 had a physical examination on 1/29/2021 and then not again until 3/30/22. This exceeds the requirement. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #2 had refused the initial appointment whereby it was rescheduled for the 3/30/22. Individual #2 refusal documentation or progress note should have been kept on his file to explain the exceeding time requirement as per the regulations. Individual #2 has an upcoming appointment on 4/3/23. |
04/03/2023
| Implemented |
| 6400.144 | Individual #2 is prescribed Trueplus 33g Lancets, test blood sugar 3x weekly at 8am. According to Individual #2 February 2023 Medication Administration Record (MAR) during the week of 2/5-2/11/23 the MAR was initialed on 2/6, 2/7, 2/8, 2/9, 2/10/ and 2/11. During the week of 2/12-2/18/23 the MAR was initialed on 2/13, 2/14, 2/15, 2/16, and 2/17. During the week of 2/19-2/25/23 the MAR was initialed on 2/20, 2/21, 2/22, and 2/23. Individual #2 has a history of refusing the blood sugar checks, and the agency is requiring the individual to have the blood sugar test done more frequently than what is prescribed. The medical service is not being provided as prescribed by the physician. | 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 #2 has an upcoming Dr. appointment that will address the testing of the blood sugar. The staff have been re-trained to only check his blood sugar 3x weekly as prescribed. The staff are to no longer check his blood sugar more than the required times by the doctor. |
03/15/2023
| Implemented |
| 6400.46(d) | Staff #2 date of hire is 7/19/22 and there is no documentation that they were trained within 6 months after the date of employment in first aid. Staff #2's received training on 6/23/22 from the American Heart Association and the card indicated Basic Life Support (CPR and AED Program). | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Staff #2 was re-trained on CPR, first aid, Heimlich techniques, and AED by a certified American Heart Association trainer on 3/9/23. Staff #2 is currently in compliance. |
03/09/2023
| Implemented |
| 6400.165(g) | Individual #2 is prescribed medication to treat symptoms of a psychiatric illness. Individual #2's had a medication review on 2/8/23 and the form used did not include the documentation of the reason for prescribing the 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 #2 psychiatrist appointment have been completed on a company designated form moving forward which include the documentation of the reason for prescribing the medication, name of the doctor prescribing medication and the individuals names and dosage. |
03/10/2023
| Implemented |
| 6400.166(a)(2) | Individual #2's Mediation Administration Record (MAR) did not list the following prescribers: Kimberly Garcia and Angela Latoorre. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | Individual #2 MAR was corrected immediately and all the Dr. names were added on it. Program coordinator contacted the pharmacy to add the names of the doctors on the MAR following the upcoming months. |
02/23/2023
| Implemented |