| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.113(a) | Individual 1 did not receive fire safety training when he joined the agency in January 2022. The only documented fire safety training in their file is dated 8/22/22. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | Jami Residences holds quarterly fire safety training for staff. These trainings are conducted by a former fire chief. We have incorporated quarterly training courses for the individuals in our agency. Every quarter when staff are scheduled for training, individuals will be scheduled for training. This will ensure that all individuals are fire safety trained over the course of year. |
12/31/2023
| Implemented |
| 6400.141(c)(11) | Individual 1's 9/29/21 physical does not contain a record of health maintenance needs. That section of the physical was blank. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | The agency nurse, or Jami staff member will prefill the physical form with current and available regarding the consumer to ensure that no sections are left blank. The prefilled information will be reviewed by the primary care physician for accuracy during the annual physical. This will allow the PCP to remove or include any additional information. If the PCP forgets to complete or sign the document, the form will be returned to the physicians office to ensure the form is completed in its entirety. |
03/19/2023
| Implemented |
| 6400.141(c)(14) | Individual 1's 9/29/21 physical does not contain information pertinent to diagnosis in case of emergency; that portion of the physical is blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The agency nurse, or Jami staff member will prefill the physical form with current and available regarding the consumer to ensure that no sections are left blank. The prefilled information will be reviewed by the primary care physician for accuracy during the annual physical. This will allow the PCP to remove or include any additional information. If the PCP forgets to complete or sign the document, the form will be returned to the physicians office to ensure the form is completed in its entirety. |
03/19/2023
| Implemented |
| 6400.141(c)(15) | Individual 1's 9/29/21 physical does not contain special diet information. | The physical examination shall include:Special instructions for the individual's diet. | A special diet marker has always been included in the consumers face sheet. The program specialist and agency nurse will review all face sheets to indicate special diets and will review quarterly/every six months indicate changes |
03/19/2023
| Implemented |
| 6400.142(c) | Most dental records reviewed for Individual 1 are incomplete. The record contains appointment reminders for different visits but no documentation from the dentist's office confirming what procedures were completed or any follow-ups needed, except for a record from the individual's wisdom tooth removal on 8/25/22. | A written record of the dental examination, including the date of the examination, the dentist's name, procedures completed and follow-up treatment recommended, shall be kept. | The agency nurse will work with the dental provider to see if there is a way all consumers can sign up for the portal system. This will allow the provider to maintain and obtain all completed medical records including the treatment summary from every appointment. Jami Residences will also provide the staff member attending each appointment with a paper copy of the medical summary form/ dental appointment form |
03/19/2023
| Implemented |
| 6400.144 | Medication AMOXICILLIN 500 mg Tablet for Ind. 1 was prescribed on 08/25/2022 and was not listed on the MAR for August or September nor logged when the medication was administered. Medication ACETAMINOPHEN 500mg and IBUPROFEN 600mg was not documented as prescribed, medication was logged as administered on the incorrect MAR's. Medication administered on August was listed on the September MAR and the September MAR had August administered dates. | 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.
| In March 2023, Jami Residences hired a medication trainer and technician. Her responsibilities are to train the staff and monitor the medication documentation for compliance. She is currently completing the train-the-trainer medication course and reviewing medication procedures. The medication trainer will work closely with the nurse to ensure that all medications are properly documented on the MAR when delivered by the pharmacy. |
03/31/2023
| Implemented |
| 6400.181(e)(3)(iii) | Individual 1's 3/16/22 assessment does not contain a record of their current level of performance and progress in personal adjustment. | The individual's current level of performance and progress in the following areas: Personal adjustment. | When completing the consumer assessment the program specialist will add a section of current levels in performances instead of incorporating all of this information into summary portion of the document |
03/19/2023
| Implemented |