| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | Prior to Individual #1 being discharged on 4/25/2023, the agency did not have an up-to date property record for the Individual's personal property. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | On June 2,2023, Staff were trained on the importance of having an up to date financial and property record for each individual and ensuring that new inventory is always accounted for. |
06/02/2023
| Implemented |
| 6400.43(b)(3) | The Chief Executive Officer failed to ensure the health and safety of Individual #1 was being protected due to the following: Through staff interviews on 5/10/2023 It became evident that no one at the agency was aware that Individual #1 was prescribed an Epinephrine injection due to a wasp allergy and did not have the medication on the individual's April 2023 medication admission record. . Individual #1's behavior support plan completed 11/15/2022 states the individual has a "seizure disorder consisting of myoclonic seizures, sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness, repeated jerking movements of the arms and legs, shaking, sweating. In the past, seizures typically occurred when the individual's sleep was disrupted. The protocol is to remain with Individual #1 for safety during a seizure. Individual #1's mother is designated health support and would like 911 contacted if the individual is seizing more than four (4) minutes, or if he has back-to-back seizures." The agency did not train staff on Individual's specific seizure protocol and were unaware of the protocol in place. Individual #1 had a podiatry appointment 5/27/2022 with a 9-week follow-up recommendation and the next appointment was completed 9/23/2022 with a 9-week follow-up recommendation, with no appointments since. On 10/21/2022 Individual #1 had an electroencephalogram ordered by a physician and there is no record of the test being completed. On 9/01/2022 Individual #1 was ordered to have blood work completed and there is no record of the health service being completed. All the 8:00pm medication administrations on 4/23/2023 and the 8:00am medication administrations on 4/24/2023 were not documented as administered on the April 2023 medication administration record. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. | 6/2/23, Staff were trained on the importance of ensuring safety within the homes and recognizing hazards within the home and what to do if safety risks are discovered and how to report and reduce risks as it pertains medication management and following the Indvidual's plan as prescribed. Safety walk thru was completed on 6/3/23 by the director of operations / CEO to ensure that the homes were in compliance as it pertains to Medication administration and current medication(s) was cross checked to what was documented on the MAR and current plan. |
06/02/2023
| Implemented |
| 6400.64(a) | On 5/10/2023, the following unsanitary conditions were observed: the dryer vent contained a buildup of lint approximately ½ inch think, there were 5 full Guinness beer bottles and one empty beer bottle in a cabinet in the garage, the first-floor bathroom sink had toothpaste, hair, and dust on the counter and the bowl of the sink , The lights in the bathroom on the first floor above the sink were covered with dust, the bathtub had a dark black substance covering the bottom and around the caulked area and had hair dried to several areas of the bathtub including the floor and walls, the oven door was covered in splattered and charred food , the refrigerator and freezer contained food particles and what appeared to be something that had spilled and dried on the base as well as the doors of both, there was a mattress cover on the mattress in the spare bedroom on the second floor that had stains and lint or dust coving the entire mattress cover, the second floor spare bedroom contained a closet what appeared to be black foam particles and debris all over the carpet, the window sill in the second floor bathroom was layered in dust and dirt, the second floor bathroom floor was covered in dust and dirt, and the second floor bathroom vent was covered in thick dust and cobwebs "Repeated Violation 8/15/2022, 12/15/2022, and 4/27/2023 et al". | Clean and sanitary conditions shall be maintained in the home. | 06/02/23 staff were trained on the importance of keeping clean and sanitary conditions which shall be maintained in home. Retrained on the importance of doing assigned tasks (chore chart) within the home - which includes dusting, removing the dryer lint, cleaning bathroom vents. |
06/02/2023
| Implemented |
| 6400.64(c) | On 5/10/2023 there were 2 black lawn size trash bags and 4 white kitchen size trash bags full of trash in the living room, and in the basement, there was trash, an old furnace filter, and boxes containing old Christmas decorations strewn in several areas. | Trash shall be removed from the premises at least once per week. | on 6/2/23 staff were retrained on the importance of making sure that Trash shall be removed from the premises at least once per week. Assigned trash days ae posted within the homes. |
06/02/2023
| Implemented |
| 6400.66 | On 5/10/2023 there was no operable lighting in the basement "Repeated Violation 8/15/2022, et al". | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| on 6/2/23 staff were retrained on the importance of ensuring that Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. On 6/2/23 the maintenance man came out to fix the light in the basement to ensure that there was adequate light available. |
06/02/2023
| Implemented |
| 6400.72(b) | On 5/10/2023 the window in the bathroom on the second floor, contained a screen which was broken at the top left corner causing a gap approximately 1 inch wide (Repeated Violation 8/15/2022, 12/15/2022, and 4/27/2023, et al). | Screens, windows and doors shall be in good repair. | on 6/2/23 staff were retrained on the importance of ensuring that Screens, windows and doors shall be in good repair. On 6/2/23 the bathroom screen was replaced and fixed by the maintenance man. |
06/02/2023
| Implemented |
| 6400.76(a) | On 5/10/2023 the second-floor spare bedroom had blinds on the window which had 6 missing panels on the left side, and the heat vent under the second-floor bathroom sink had a plastic cover broken off, on the floor "Repeated Violation 9/20/2022 and 4/27/2023, et al". | Furniture and equipment shall be nonhazardous, clean and sturdy. | on 6/2/23 staff were retrained on the importance of ensuring that Furniture and equipment shall be nonhazardous, clean and sturdy. The blinds were replaced by new window coverings, curtains, and the heat cover fixed by 6/3/23. |
06/03/2023
| Implemented |
| 6400.82(f) | On 5/10/2023 the second-floor bathroom did not have soap, toilet paper, and paper or cloth towels "Repeated Violation- 9/20/2022, et al". | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | on 6/2/23 staff were retrained on the importance of ensuring that Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. |
06/02/2023
| Implemented |
| 6400.110(e) | The home has three stories and on 5/10/2023 the smoke detectors tested to not be interconnected with the basement smoke alarm at 12:19pm "Repeated Violation- 9/20/2022, et al". | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | on 6/2/23 staff were retrained on the importance of ensuring that If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. The smoke detector was reconnected and worked as interconnected smoke detectors and tested on 6/2/23 |
06/02/2023
| Implemented |
| 6400.114(a) | Individual #1 had a physical examination completed 3/07/2022 and then again 3/29/2023 "Repeated Violation- 9/20/2022, et al". | If an individual or staff person smokes at the home, there shall be written smoking safety procedures. | on 6/2/23 staff were retrained on the importance of ensuring that If an individual or staff person smokes at the home, there shall be written smoking safety procedures. |
06/02/2023
| Implemented |
| 6400.141(c)(4) | Individual #1's physical examination completed 3/07/2022 did not include a vision screening. It was left blank. Individual #1's physical examination completed 3/29/2023 states unable to complete vision and hearing screening. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | on 6/2/23 staff were retrained on the importance of ensuring that the physical examination shall include Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Also reviewed was a sample physical form and the comments of it and all information that needs to be addressed. |
06/02/2023
| Implemented |
| 6400.142(a) | Individual #1 had a dental examination completed 12/21/2021 and not again since. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | on 6/2/23 staff were retrained on the importance of ensuring that An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. A shared medical calendar was created for each Indvidual as of 6/30/23 that has current and follow up reminders for the next visit to be added. |
06/30/2023
| Implemented |
| 6400.142(h) | Individual #1 has no record of having a dental hygiene plan and Individual #1's individual support plan, last updated 5/04/2022, states the individual needs physical assistance to maintain hygiene, including brushing teeth. | The dental hygiene plan shall be kept in the individual's record. | on 6/2/23 staff were retrained on the importance of ensuring that the dental hygiene plan shall be kept in the individual's record. Reviewed also where the dental hygiene plan is found within the books and what document might reference it - dental hygiene plan is located on our demographic sheets and also in the assessments. ` |
06/02/2023
| Implemented |
| 6400.144 | Individual #1's behavior support plan completed 11/15/2022 states the individual has a "seizure disorder consisting of myoclonic seizures, sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness, repeated jerking movements of the arms and legs, shaking, sweating. In the past, seizures typically occurred when the individual's sleep was disrupted. The protocol is to remain with Individual #1 for safety during a seizure. Individual #1's mother is designated health support and would like 911 contacted if the individual is seizing more than four (4) minutes, or if he has back-to-back seizures." The agency did not train staff on Individual's specific seizure protocol and were unaware of the protocol in place. Individual #1 had a podiatry appointment 5/27/2022 with a 9-week follow-up recommendation and the next appointment was completed 9/23/2022 with a 9-week follow-up recommendation, with no appointments since. On 10/21/2022 Individual #1 had an electroencephalogram ordered by a physician and there is no record of the test being completed. On 9/01/2022 Individual #1 was ordered to have blood work completed and there is no record of the health service being completed. | 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.
| on 6/2/23 staff were retrained on the importance of ensuring that 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. Online access was created to medical/health portals for all clients as of 6/30/23 and staff trained on the importance of following an individual's plan and protocols. |
06/30/2023
| Implemented |
| 6400.212(b) | Individual #1's physical examination completed 3/29/2023 documents a Tuberculin skin test read on 3/31/2023 with a negative result. The physician signed the physical examination 3/29/2023 and there is no credentials or signature for the person who added the Tuberculin results 3/31/2023. | Entries in an individual's record shall be legible, dated and signed by the person making the entry.
| on 6/2/23 staff were retrained on the importance of ensuring that Entries in an individual's record shall be legible, dated and signed by the person making the entry. Also reviewed was a sample physical form and the comments of it and all information that needs to be addressed. |
06/02/2023
| Implemented |
| 6400.163(h) | Individual #1 was discharged from the agency on 4/28/2023. On 5/10/2023 10 full Divalproex 125mg capsule medication packs, 3 tubes of Calcipotriene 0>0005% cream, and 2 tubes of Hydrocortisone Cream prescribed to Individual #1 were identified locked in the medication cabinet. The prescribed Divalproex 125mg capsule, take 1 tablet by mouth twice a day for mood was discontinued on 9/02/2022. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | on 6/2/23 staff were retrained on the importance of ensuring that A prescription medication shall be prescribed in writing by an authorized prescriber. Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. The process of medication returns to PDC pharmacy were also discussed. Also reviewed was the process for discharge during which includes a med count for all supplies. |
06/02/2023
| Implemented |
| 6400.165(a) | On 5/10/2023 Sulfur Medicated Original Formula Anti-dandruff hair & scalp conditioner, with instructions to apply to affected area 1-4 times daily or as directed by a doctor, was identified locked in Individual #1's medication cabinet and the individual did not have a prescription by an authorized prescriber for the medication. Individual #1's April 2023 medication administration record documented administrations of Calcium D3 600mg tablet for vitamin supplement from 4/01/2023 through 4/23/2023 at 8:00am and 8:00pm and on 4/24/2023 at 8:00am. There is no current order for this medication. | A prescription medication shall be prescribed in writing by an authorized prescriber. | on 6/2/23 staff were retrained on the importance of ensuring that A prescription medication shall be prescribed in writing by an authorized prescriber. |
06/02/2023
| Implemented |
| 6400.165(e) | Individual #1 was prescribed Ketoconazole Shampoo 2%, use to wash hair twice weekly as directed by doctor for scalp irritation. The 3/01/2023, 3/02/2023, and 3/03/2023 administration were initialed at 8:00pm and then crossed out with a line and no other administrations documented on the March 2023 nor April 2023 medication administration record. | Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received. | on 6/2/23 staff were retrained on the importance of ensuring that Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received. |
06/02/2023
| Implemented |
| 6400.165(g) | Individual #1, date of admission 4/19/2021, is prescribed Divalproex 250mg DR tablet for mood, and has no record of having a medication review by a licensed physician "Repeated Violation- 3/17/2022 and 12/15/2022, et al". | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | on 6/2/23 staff were retrained on the importance of ensuring that If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. Online calendar created for all clients with reminder s for frequency of specific doctors' appointments listed. |
06/02/2023
| Implemented |
| 6400.166(a)(4) | Individual #1 was prescribed Epinephrine .3mg/ml injection, inject .3ml one time as needed for allergic reaction up to one dose intramuscular, and Individual #1's April 2023 medication administration record did not include the name of the medication "Repeated Violation 8/15/2022, 11/01/2022, and 4/27/2023, et al". | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | on 6/2/23 staff were retrained on the importance of ensuring that A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. |
06/02/2023
| Implemented |
| 6400.166(a)(5) | Individual #1 was prescribed Epinephrine .3mg/ml injection, inject .3ml one time as needed for allergic reaction up to one dose intramuscular, and Individual #1's April 2023 medication administration record did not include the strength of the medication "Repeated Violation 8/15/2022, 11/01/2022, 12/15/2022, and 4/27/2023, et al". | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | on 6/2/23 staff were retrained on the importance of ensuring that A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. |
06/02/2023
| Implemented |
| 6400.166(a)(6) | Individual #1 was prescribed Epinephrine .3mg/ml injection, inject .3ml one time as needed for allergic reaction up to one dose intramuscular, and Individual #1's April 2023 medication administration record did not include the dosage form for the medication "Repeated Violation 8/15/2022 and 4/27/2023, et al". | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | on 6/2/23 staff were retrained on the importance of ensuring that A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. |
06/02/2023
| Implemented |
| 6400.166(a)(7) | Individual #1 was prescribed Epinephrine .3mg/ml injection, inject .3ml one time as needed for allergic reaction up to one dose intramuscular, and Individual #1's April 2023 medication administration record did not include the dose for the medication "Repeated Violation 8/15/2022 and 4/27/2023, et al". | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | on 6/2/23 staff were retrained on the importance of ensuring that A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. |
06/02/2023
| Implemented |
| 6400.166(a)(8) | Individual #1 was prescribed Epinephrine .3mg/ml injection, inject .3ml one time as needed for allergic reaction up to one dose intramuscular, and Individual #1's April 2023 medication administration record did not include the route of administration for the medication "Repeated Violation 8/15/2022 and 4/27/2023, et al". | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | on 6/2/23 staff were retrained on the importance of ensuring that a medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. |
06/02/2023
| Implemented |
| 6400.166(a)(9) | Individual #1 was prescribed Epinephrine .3mg/ml injection, inject .3ml one time as needed for allergic reaction up to one dose intramuscular, and Individual #1's April 2023 medication administration record did not include the frequency of administration for the medication "Repeated Violation 8/15/2022, 12/15/2022, and 4/27/2023, et al". | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | on 6/2/23 staff were retrained on the importance of ensuring that a A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. |
06/02/2023
| Implemented |
| 6400.166(a)(11) | Individual #1 was prescribed Epinephrine .3mg/ml injection, inject .3ml one time as needed for allergic reaction up to one dose intramuscular, and Individual #1's April 2023 medication administration record did not include the diagnosis or purpose for the medication "Repeated Violation 8/15/2022 and 4/27/2023 et al". | 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. | on 6/2/23 staff were retrained on the importance of ensuring that 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. |
06/02/2023
| Implemented |
| 6400.166(b) | Individual #1 was discharged from the agency at 12:00pm on 4/25/2023 and the following administrations were not documented on Individual #1's May 2023 medication admission record: Divalproex 250mg DR on 4/24/2023 at 8:00pm and on 4/25/2023 at 8:00am, Fluoxetine 20mg capsule on 4/25/2023 at 8:00am, Fluoxetine 40mg capsule on 4/25/2023 at 8:00am, Aripiprazole 15mg tablet on 4/24/2023 at 8:00pm, Vitamin D3 5000 unit capsule on 4/25/2023 at 8:00am, Labetalol 100mg tablet on 4/24/2023 at 2:00pm, 4/24/2023 at 8:00pm, and 4/25/2023 at 8:00am, and Loratadine 10mg tablet on 4/25/2023 at 8:00am. Individual #1 was prescribed Calcipotriene 0.005% cream, apply topically to affected area twice a day for 4 weeks for skin irritation. Individual #1's April 2023 medication administration record did not document any administrations in April 2023 and was on the current medication list from the physical examination completed 3/29/2023. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | on 6/2/23 staff were retrained on the importance of ensuring that information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. |
06/02/2023
| Implemented |