| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(e)(1) | It cannot be determined what deposits and withdrawals were made to individual 1's account as the ledger provided consistently ended the month with negative ledger balances. Each expense and deposit was not itemized to show actual transactions for the client. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. | .The financial Manager
a. To ensure the prevention of this in the future, all finances will be monitored by the
Financial Manager and CEO.
b. Financial Manger will ensure all deposits of resident¿s financial resources are recorded
properly in the ledger.
c. Financial Manager will track all signatures, receipts, and petty cash count to ensure all
expenses and withdrawals are properly handled and recorded.
d. Financial Manager will log all information on the budget forms identifying all income
and expenses for each resident.
e. Financial Manager will create a budget for each resident so that onsite staff are not
providing additional funds outside of budgeted resources. |
04/01/2020
| Implemented |
| 6400.77(b) | There were no tweezers found in the first aid kit at the time of review. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | A checklist will be created and the Administrative Assistant will check all kits monthly. The Admin assistant will compile a list of missing items and forward to the facilities coordinator, for ordering. |
04/01/2020
| Implemented |
| 6400.112(a) | There was no fire drill documented for the month of march 2019. | An unannounced fire drill shall be held at least once a month. | The program specialist and House Manager will ensure an unannounced fire drill will scheduled month to make sure that all fire drills are completed regularly conducted. The program specialist will monitor all monthly drill s calendar in google calendar to keep track of the unannounced drills |
04/01/2020
| Implemented |
| 6400.112(c) | The fire drill dated 3/8/20 did not notate the time it took place. The form only notated "PM" | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | All staff will participate in refresher documentation writing course to ensure that forms including the fire drill document are completed correctly |
06/30/2020
| Implemented |
| 6400.163(a) | Two unknown tablets prescribed to individual 1 fell out of a previously punctured AM blister pack while reviewing the medications. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | All medication will be kept in a locked file cabinet in its original blister pack. The agency will hire a consultant will be reviewing all of Jami Residence training records to identify additional non compliances staff training. Retrain staff on required trainings if the Jami Residence staff is discovered to be out of compliance. |
06/30/2020
| Implemented |
| 6400.166(a)(12) | Medications prescribed to individual 1, carbamazepine 200 mg and metformin 500 mg to be taken in the morning were not signed for when administered for the entire month of March 2020, (nine days). Inspection was held on 3/9/2020 | 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. | The agency will hire a consultant will be reviewing all of Jami Residence training records to identify additional non compliances staff training. Retrain staff on required trainings if the Jami Residence staff is discovered to be out of compliance |
06/30/2020
| Implemented |
| 6400.166(a)(13) | Medications for Individual 1, carbamazepine 200 mg, prazosin 1 mg and metformin 500 mg to be taken during PM hours were not signed for when administered for the entire month of March 2020. Date of inspection was March 9 2020. These medications are packaged together in one blister pack grouped by time of dosage and when the blister pack combo is administered, staff is only signing as administering the first listed medication only on the medication administration record. | 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. | The agency will hire a consultant will be reviewing all of Jami Residence training records to identify additional non compliances staff training. Retrain staff on required trainings if the Jami Residence staff is discovered to be out of compliance and to ensure that staff are medication certified and for those employees that need a refresher course |
06/30/2020
| Implemented |