| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(e) | There were no fire drills conducted during sleeping hours. Sleeping hours are from 11pm to 7am. None of the fire drills held from 12/18/19 through 7/23/20 were conducted during those times. | A fire drill shall be held during sleeping hours at least every 6 months. | It is important to measure if an individual can get out of a home safely and timely if a fire occurs while the individual is asleep. The last sleep fire drill was held after 7:00am. It is the responsibility of the program specialist to ensure that sleep drills are held between 11pm and 7am. The program specialist will train all direct support staff to conduct sleep drills between the hours of 1am and 3am as instructed. This will ensure that the data collected reflects a true sleeping drill. The program specialist and all direct support staff will be trained on this regulation by 9/30/2020. A proper sleep drill will be conducted in August. |
09/30/2020
| Implemented |
| 6400.112(g) | There were no fire drills completed during evening or nighttime hours. All of the fire drills are occurring between 10:20am and 3:24pm | Fire drills shall be held on different days of the week and at different times of the day and night. | It is important to measure if an individual can get out of a home safely and timely if a fire occurs any time of the day. There were no fire drills conducted in the evening or night time hours. The program specialist will train all direct support staff to conduct sleep drills between the hours of 1am and 3am as instructed, and to alternate between morning, evening, and night. The program specialist and all direct support staff will be trained on this regulation by 9/30/2020. |
09/30/2020
| Implemented |
| 6400.141(c)(12) | The most recent physical form for individual #1 dated 2/10/2020 had a box for physical limitations and it was prefilled stating, "sensitivity to lactose" which was actually meant for the "Special dietary instructions" box which was left blank. Thus, there wasn't any information regarding physical limitations and was technically left blank. There should have been documented "NA" or "none" should that be the situation. | The physical examination shall include: Physical limitations of the individual. | It is important for the medical treatment of the individual that the physical form is filled out correctly when prefilling medical information. The medical coordinator prefilled sensitivity to lactose in the wrong box. The medical coordinator will be re-trained on this regulation by 9/30/2020. All agency physical forms will be reviewed to check for this error and corrected if need be by 9/30/2020. |
09/30/2020
| Implemented |
| 6400.141(c)(14) | The most recent physical form for individual #1 dated 2/10/2020, did not contain medical information pertinent to diagnosis and treatment in case of an emergency rather it only listed the CEO name and phone number. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | It is important for the medical treatment of the individual that the physical form is filled out correctly when prefilling medical information. The medical coordinator prefilled the emergency contact information of the individual in the box that required information pertinent to diagnosis and treatment in case of an emergency. The medical coordinator will be re-trained on this regulation by 9/30/2020. All agency physical forms will be reviewed to check for this error and corrected if need be by 9/30/2020. |
09/30/2020
| Implemented |
| 6400.211(b)(1) | Individual #1's chart included the name, phone number and relationship of the designated person to be contacted in case of an emergency, but it did not contain the address. | Emergency information for each individual shall include the following: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency.
| In case of an emergency it is imperative that support staff know not only who to contact, but where to contact them. Individual #1s chart included the name and phone number of the emergency contact but not the address. It is the responsibility of the program specialist to ensure that the emergency contact information is available and accurate. Individual #1s record was updated (Attachment #1). All records of the individuals we serve will be reviewed and corrected to include the address of the emergency contact by 9/30/2020 |
09/30/2020
| Implemented |
| 6400.31(b) | The Individual Rights form that Individual #1 signed upon admission (12/18/2019) did not encompass all of the individual's rights information covered in regulations 31c through 32v. The form needs to be updated in order for the individual to understand all of the individual rights upon admission. | The home shall educate, assist and provide the accommodation necessary for the individual to make choices and understand the individual's rights. | To ensure that a civil rights violation does not occur it is imperative that all rights of the individual are disclosed to them. During inspection it was found that the civil rights form did not include every aspect of the individuals rights. The compliance manager is responsible for the creation and implementation of this form and it is the program specialists responsibility to train staff and individual¿s on it. Individual #1s form will be corrected by 9/30/2020. Since the form is incorrect, every other individual¿s forms will be corrected by 9/30/2020. The program specialist and the compliance manager will be retrained on this regulation by 9/30/2020. |
09/30/2020
| Implemented |
| 6400.166(a)(13) | On the MAR dated 6/02/2020, staff #1 initialed that PRN medication "Perphenazine" was administered, however according to a medication administration note completed on 6/3/2020, the staff member actually administered PRN medication "Cogentin" instead. The initials of staff #1 were not corrected on the Medication Administration Record (MAR), nor a staffing notation given on the back of the MAR to correctly reflect which medication was actually given on 6/02/2020. | 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. | When administering medications, it is the responsibility of all trained medication administration staff to administer the right drug at the right time to the right person. On Individual #1s record, direct support staff administered the wrong drug but did not correct the MAR. A medication administration note was completed for this error, and the error reported; however, the staff did not correct the MAR. A new procedure has been implemented that the errors such as this be noted on the back of the MAR as well as a note and timely reporting to EIM. It will be the responsibility of the medical coordinator to monitor. All medication administration staff will be trained on this regulation by 9/30/2020. |
09/30/2020
| Implemented |