| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Dryer Lint present in dryer | Clean and sanitary conditions shall be maintained in the home. | On 12/12/22 Direct care staff and management were trained on the importance of maintaining clean and sanitary conditions within the home. as it pertains to the dryer lint trap. The dryer lint trap was cleaned (see attachment #1) on 12/12/2022. The importance of removing all dryer lint after each load was discussed/reviewed with individual #1 and individual #2 and all staff as well. |
01/09/2023
| Implemented |
| 6400.67(a) | There is a drawer in kitchen that is broken. The front piece of wood was pulled off of the rest of the drawer and was resting inside. | Floors, walls, ceilings and other surfaces shall be in good repair. | on 12/12/22 Direct care staff and management were trained on the importance of ensuring that Floors, walls, ceilings and other surfaces shall be in good repair (attachment #10).
The drawer in the kitchen was repaired by the handyman on 1/09/23 (attachment #3) and is currently in working order. |
01/09/2023
| Implemented |
| 6400.110(b) | The only Smoke detector in the home is located in the living room area which is greater than 15 feet from the individuals' bedrooms. | There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. | On 12/12/22 Direct care staff and management were trained on the importance of ensuring that there shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door (attachment #10). On 12/14/22 a new smoke detector was purchased and installed less than 15 feet from the individual's bedroom (attachment#4). Staff also participated in an annual refresher fire safety training on 1/6/23 (attachment #11)
Fire drill was completed on 12/14/22. (Attachment #5) and in January 2023 with no concerns noted and new smoke detector installed. |
01/09/2023
| Implemented |
| 6400.144 | Medical services have not been provided consistently for Individual 1. Many follow-up visits and medical orders have not been completed timely. Their 8/4/21 podiatry visit called for a follow-up on 11/3/21; records do not show this was completed. A 2/16/21 urology visit called for a follow-up within 3 months; agency records indicate they did not see their urologist again until 2/16/22. Their record does not contain documentation of OB/GYN appointments; their last flu shot was over a year ago on 9/17/21; and their 5/24/22 physical calls for a shingles vaccine, labs, and reestablishing psychiatric care, none of which have yet been completed. On 9/12/22, labs were ordered but their results are not captured in documentation; the agency indicates they've scheduled new labs for 12/23/22. Their last TB test was over two years ago, dated 10/2/20; the agency indicates they've scheduled a new test for 12/23/22. Individual 1's MAR called for a PRN triamcinolone 0.1% cream; it was not available in their medication kit. During the inspection, the agency provided a discontinuation order for the medication, dated 12/13/22. Also, Individual 2's MAR lists Miralax with two different administrations: daily and PRN. Their medication kit only included a Miralax bottle with the PRN instructions; there was not also a bottle with daily administration orders. | 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 12/12/22 Direct care staff and management were trained on the importance of 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 (attachment #10).
individual #1- records for podiatry were in the medical book for individual #1 but not properly filed- she did attend the appointment on 11/3/2021(attachment #6), after a book audit on 1/13/2023 to check for overall appointment compliance, the podiatry paperwork was refiled under the correct tab. current/upcoming podiatry appointment is on 2/14/23 @ 11:15am.
individual # 1 urology appointment -11/20/2020 (follow up in three months), 1/7/2021 ,2/16/2021 follow up in one year(attachment #7) , 2/16/2022 next scheduled 2/15/2023. currently compliant
individual #1 - 11/2/2020 and next is OBGYN appointment scheduled for 4/16/2023.( attachment #8)
Individual #1 last flu shot was administered by gateway pharmacy in 9/21/2022. (Attachment #9)
Individual #1 - shingles vaccine counseled and 4/8/23 physical and psyche, psyche appointment for med review of 4/4/23. (Attachment #12)
individual # 1 labs were complete on 12/23/22. (Attachment #13)
individual #1 - tb test done on 6/10/22 (attachment #14)
individual #1-1's MAR called for a PRN triamcinolone 0.1% cream; it was not available in their medication kit. During the inspection, the agency provided a discontinuation order for the medication, dated 12/13/22. it was removed. current MAR does not reflect ointment. (Attachment #15)
individual #1- Also, Individual 2's MAR lists MiraLAX with two different administrations: daily and PRN.
Their medication kit only included a MiraLAX bottle with the PRN instructions; there was not also a bottle with daily administration orders- the MAR was updated to reflect updated orders (attachment #16) |
01/09/2023
| Implemented |
| 6400.163(h) | Individual 2's medication kit included a PRN container of Vaseline that was expired and not listed on the MAR; its pharmacy label listed 5/17/22 as its discard date. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | On 12/12/22 Direct care staff and management were trained on the importance of ensuring that Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations (attachment #10). On the day of the unannounced monitoring the Vaseline was removed from the box. (Attachment #18) |
01/09/2023
| Implemented |
| 6400.165(g) | Individual 1 is on risperidone, a psychotropic medication; agency records do not indicate they are receiving psychotropic medication management appointments every 3 months. | 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 12/12/22 Direct care staff and management were trained on the importance of ensuring that 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( attachment #10).Management staff called the PCP office, prescribing doctor, and they confirmed psyche med reviews were completed in 2022 by a licensed physician and labs drawn to check therapeutic levels of the medication. confirmation consults of the previous psyche appointment were sent to caresense living (attachment #18) |
01/09/2023
| Implemented |
| 6400.207(4)(IV) | Individual 2 has chlorpromazine listed as a PRN medication, to be administered in two tablets once per day as needed for psychotic behavior and aggression. Psychotropic medications cannot be administered on a PRN basis; the order must clearly specify times it is to be used (for example, how often per day or week, or prior to doctor's appointments), or be administered by a medical professional. | A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: A specific, time-limited stressful event or situation to assist the individual to control the individual's own behavior. | On 12/12/22 Direct care staff and management were trained on the importance of ensuring that no psychotropic medications are not administered on a PRN basis; and reviewed with the order must clearly specify times it is to be used (for example, how often per day or week, or prior to doctor's appointments), or be administered by a medical professional. (Attachment # 10)
individual attended a doctor's appointment on 12/27/22 and the medication was discontinued, and MAR updated (attachment #19) |
01/09/2023
| Implemented |