| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.73(a) | The attic has two steps, and then it has three steps with no railing. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | At the time of the inspection it was found that there is not a wall secured handrail with the three steps leading up to the attic. Although the attic is locked at all times due to a restrictive behavior support plan a railing will be installed for the three steps leading to the attic for the safety of the individual and the staff in the event, they would get access to the attic. CEO will be retrained that any ramp, interior stairway, and outside steps exceeding two steps have a wall-secured handrail. |
09/30/2021
| Implemented |
| 6400.169(a) | The documentation received indicates that Staff # 2 received Initial Medication Training on 05/10/17. Staff # 2 did not complete an annual Practicum in 2018 (a hand written note on the document reads, "Left 04/01/18"). There is no date of completion listed on the Annual Practicum form which was signed by the Medication Trainer on 06/27/20. The space was left blank. Staff # 1 confirmed during the annual inspection that Staff # 2 has been passing medications since 06/27/20. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | At the time of the inspection it was found that Staff #1 should have completed a full medication administration retraining in 2018 when returning to employment. Medication Administration Trainer was retrained on importance of staffs training being up to date and complete. Staff #1 completed a new department approved medication course including med passes and observations by the medication administration trainer. |
07/30/2021
| Implemented |
| 6400.169(d) | There is no "Date of Completion" filled in on Staff # 1's Annual Medication Administration practicum which was signed by the Medication trainer on 06/07/21. The space was left blank.
There is no date of completion listed on Staff # 2's Annual Practicum form which was signed by the Medication Trainer on 06/27/20. The space was left blank.
There is no date of completion listed on Staff # 3's Annual Practicum form which was signed by the Medication Trainer on 06/27/20. The space was left blank. | A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed. | At the time of the inspection it was found that staff #1 had completed the annual practicum in its entirety, however, the completion date was not listed on the annual form. It is important for all lines on the form to be filled out and the form to be completed in its entirety. Medication Administration Trainer was retrained on importance of staffs training being up to date and complete. Staff # 1 completed a new department approved medication course including med passes and observations by the medication administration trainer. |
07/30/2021
| Implemented |
| 6400.186 | Individual # 1's ISP 6/21/2021 states a lactose free diet. This is not a physician's order from what the provider has stated. There is no documentation of this. Provider states that that the individual's mother advises a lactose free diet for her son. The ISP is the only documentation that states a lactose free diet. | The home shall implement the individual plan, including revisions. | At the time of the inspection it was discovered that a historical diet was listed in the ISP. Provider had sent track changes to Supports Coordinator asking for the information to be removed but did not follow up with SC to ensure the ISP stayed up to date and accurate. Program Specialist will be retrained t to follow up in writing with all Supports Coordinators after 1 week and their supervisor after 2 weeks if track changes are not implemented into the ISP as requested. |
07/30/2021
| Implemented |