| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | There was no self-assessment completed for this home. | 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. | The self-assessments for 2021 were incomplete because all administrative personnel were working providing direct support in the homes. Greater Hearts will be doing self-assessments for all homes by 5/1/22.. The self-assessments will include vacant homes as well. |
04/27/2022
| Implemented |
| 6400.104 | The 11/16/21 notification to local fire department lists only Individual #1 as living in the home, and does not list Individual #2. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| A corrected notification to the fire department that included both individuals in the home was sent to the fire department on 4/5/22 and submitted to the licensing staff on 4/6/22. |
04/05/2022
| Implemented |
| 6400.34(a) | The Department issued updated regulatory rights, effective 2/3/2020, stating that individuals have additional rights they need to be informed of. At the time of the 4/05/2022 annual inspection, Individual #1 was never informed of the individual rights as described in 6400.32. | 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. | Program manager corrected the error and reviewed the updated rights documents with the individual. This document was shared with licensing staff at the office on 4.7.22 |
04/15/2022
| Implemented |
| 6400.52(b)(1) | Staff #1 has a record of 8.5 training hours for the training year 1/1/21-12/31/21. | The following shall complete 12 hours of training each year: Management, program, administrative and fiscal staff persons. | A meeting was conducted with the CEO to discuss training hours on 4/12/22. |
04/25/2022
| Implemented |
| 6400.166(a)(11) | (REPEAT from inspection completed on 1/20/21) The 02/2022 Medication Administration Record (MAR) for Individual #1 does not include the diagnosis or purpose for "Divalproex" 500mg DR or "Loratadine" TAB 10mg. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | When individual #1 moved into the home in November 2021 the scripts didn't have a diagnosis for a couple of the medications. On 4.6.22 Medication trainer reached out to the pharmacy and the individuals providers to request that diagnosis be added to the medications in question. The pharmacy received scripts with diagnoses on them as requested. Please see attached "MAR with diagnoses" on them. All doctors were contacted and we are currently waiting on a response . Greater Hearts will continue to work with the pharmacy to ensure doctors give diagnosis on new medications before they come to the home. The diagnosis will be added to all MAR's by 5/1/22. |
04/21/2022
| Implemented |