| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.65 | There is no ventilation either by a window or mechanical devise in the bathroom. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Violation 65 was corrected accordingly.
See attachment #30 |
| Implemented |
| 6400.67(b) | The filter located in the dryer was full of lint the size of a golf ball, which poses a fire hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Violation 67 (b) was corrected including staff training and mandatory signature tracking sheet for all sites as applicable. See attachment #31. |
04/29/2023
| Implemented |
| 6400.68(b) | The water in the tub measured 131.7*F | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Violation 68 (b) was corrected accordingly. See attachment #32. |
04/29/2023
| Implemented |
| 6400.82(f) | There is no individual clean paper or cloth towel in the downstairs bathroom. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Violation 82 (f) was corrected accordingly. See attachment #33. |
04/29/2023
| Implemented |
| 6400.141(c)(6) | The Tuberculin (TB) test for individual one was not read with negative results every two years. The TB test was last read on 4/8/2021 according to the 4/11/23 physical examination. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Violation 141 (c) (6) was identified on individual one file the same day of inspection. See attachment #34. |
04/28/2023
| Implemented |
| 6400.143(a) | The refusal for individual one along with the continued attempts to train the individual as to the need for health care of medical treatment, medication administration in particular was not documented for the refusals of the following medication: sertraline, metformin, mupirocin, norethindrone, Symbicort, Lisinopril , loratadine, Senna Plus for the month of April was not provided. Individual one refused morning doses of all medication regularly. | 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. | Violation 141 (a) has been corrected. PCP was notified about Individual one refusal of routine medication. as well as individual retrained on need for health care. Individual declined training and form has been attached. See attachments # 62- 65. |
05/01/2023
| Implemented |
| 6400.144 | All medication on 04/19/23 was signed as administered but the medication remained in the blister pack. Medication MUPIROCIN 2% OINTMENT not on-site at time of inspection, but was signed as administered. | 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.
| Violation 141 has been corrected. Staff has been retrained on medication administration and documentation. Mupirocin was refilled on 4/27/2023. See Ointment attachment #66 and trainings for staff attachment 47-56, & 66. |
05/03/2023
| Implemented |
| 6400.34(a) | The individual rights form signed by individual one on 2/28/23 did not cover all the current up-to-date rights. The right of bedroom privacy and adaptive technology was not notated as discussed. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Agape Family Home LLC updated the Individual Rights statement to reflect the current up to date rights. All The new updates form has now been adopted for all individuals. The new rights have been explained to the individuals who have signed them accordingly. The new Rights include right to bedroom privacy and technology usage. Please see attachment 29 |
08/08/2023
| Implemented |
| 6400.163(d) | Medications for individual one were not kept locked, the closet that house the medication was left open. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | Violation 163 (d) has been corrected. Staff has been retrained on the importance of safety to prevent unauthorize access to medication. See attachments #2 |
05/02/2023
| Implemented |
| 6400.165(c) | All 8am medications for individual 1 were not administered as prescribed. | A prescription medication shall be administered as prescribed. | Violation 165 (c) has been corrected. Staff has been retrained on medication administration and documentation. See attachments #47-56. |
05/03/2023
| Implemented |
| 6400.165(g) | Documentation for the reason for prescribing psychotropic medication was not provided every 90 days in between the medication reviews of 6/30/22 and 3/21/23 for individual 1. | 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. | Violation 165 (g) is pending Physician's response to submit paperwork. |
06/09/2023
| Implemented |
| 6400.166(a)(12) | On 04/04/2023, the staff failed to initial individual one's MAR for the 8am dosage that was administered. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration. | Violation 166 (a) (12) has been corrected. Staff has been retrained on medication administration and documentation. See attachments #47-56. |
05/03/2023
| Implemented |
| 6400.166(a)(13) | Medication MUPIROCIN 2% OINTMENT and LITHUIM CARBONATE 300mg was not initialed as administered for individual one on 04/10/2023. | 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. | Violation 166 (a) (13) has been corrected. Staff has been retrained on medication administration and documentation. See attachments #47-56. |
05/03/2023
| Implemented |
| 6400.166(c) | Individual one's refusals were not documented as reported to prescriber for potential harm to the individual for refusing the medication. Individual one refused morning medications regularly but documentation was not provided notating contact to the prescriber. | If an individual refuses to take a prescribed medication, the refusal shall be documented on the medication record. The refusal shall be reported to the prescriber as directed by the prescriber or if there is harm to the individual. | Violation 166 (c) (12) has been corrected. Staff has been retrained on medication administration and documentation. See training attachments #47-56. See MAR for the month of April attachments #68 -70 |
05/03/2023
| Implemented |
| 6400.181(f) | Verification that Individual One's assessment on 1/5/2023 was sent 30 days prior to the ISP was not provided. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Violation 181 (f) was corrected accordingly. See attachment #66 |
04/29/2023
| Implemented |
| 6400.183(c) | The most current Individual plan meeting and sign in sheets were not documented for individual One. | The list of persons who participated in the individual plan meeting shall be kept. | Violation 181 (c) was corrected accordingly. See attachment #43 |
04/29/2023
| Implemented |