Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.22(d)(1) | Documentation of funds received by the home for Individual #1 were requested and not received. It could not be determined that up to date financial records of deposits made to the home for Individual #1 were kept. Per CareSense assessment for Individual #1 dated 4/03/21 "Joan is unable to maintain her funds safely. She would need total staff assistance. There have been no changes in this area." | 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. | Both the lead staff and program coordinator were retrained on the client fund process . Individual #1 funds wee reconciled and inputted into an online system that automatically calculates funds , the goal would de to better track the receipts and balances. Although CareSense is not the current rep payee , any funds at the home for individual #1 will be tracked accordingly and reconciled. All client funds for ind. #1 is reconciled. |
04/02/2021
| Implemented |
6400.22(d)(2) | Documentation of disbursements made to or for Individual #1 were requested and not received. It could not be determined that up to date financial records of disbursements made to or for the individual were kept. Per CareSense assessment for Individual #1 dated 4/03/21 "Joan is unable to maintain her funds safely. She would need total staff assistance. There have been no changes in this area." | (2) Disbursements made to or for the individual.
| Both the lead staff and program coordinator were retrained on the client fund process . Individual #1 funds were reconciled ( deposits and wihdrawals and inputted into an online system that automatically calculates funds , the goal would de to better track the receipts and balances. Although CareSense is not the current rep payee , any funds at the home for individual #1 will be tracked accordingly and reconciled. All client funds for ind. #1 is reconciled. |
04/02/2021
| Implemented |
6400.22(e)(1) | Documentation of dates and amounts of deposits and withdraws for Individual #1 were requested and not received. It could not be determined that a record of financial resources, including the dates and amounts of deposits and withdrawals were kept. Per CareSense assessment for Individual #1 dated 4/03/21 "Joan is unable to maintain her funds safely. She would need total staff assistance. There have been no changes in this area." | 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. | Although CareSense is not the current rep payee , any funds at the home for individual #1 will be tracked accordingly and reconciled. All client funds for ind. #1 is reconciled. Both the lead staff and program coordinator were retrained on the client fund process . Individual #1 funds were reconciled ( deposits and withdrawals and inputted into an online system that automatically calculates funds , the goal is to track better the receipts and balances. |
04/02/2021
| Implemented |
6400.22(e)(2) | Documentation of financial transactions for Individual #1 were requested and not received. It could not be determined that withdrawals were properly logged as required. Per CareSense assessment for Individual #1 dated 4/03/21 "Joan is unable to maintain her funds safely. She would need total staff assistance. There have been no changes in this area." | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: For a withdrawal when the individual is given the money directly, the record shall indicate that funds were given directly to the individual. | Both the lead staff and program coordinator were retrained on the client fund process . Individual #1 funds were reconciled ( deposits and wihdrawals and inputted into an online system that automatically calculates funds , the goal is to track better the receipts and balances. Although CareSense is not the current rep payee , any funds at the home for individual #1 will be tracked accordingly and reconciled. All client funds for ind. #1 is reconciled. |
04/02/2021
| Implemented |
6400.22(e)(3) | Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person was requested and not received for Individual #1. It could not be determined that receipts and/or expense records were kept satisfying regulation. Per CareSense assessment for Individual #1 dated 4/03/21 "Joan is unable to maintain her funds safely. She would need total staff assistance. There have been no changes in this area." | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | Both the lead staff and program coordinator were retrained on the client fund process . Individual #1 funds were reconciled ( deposits and wihdrawals and inputted into an online system that automatically calculates funds , the goal is to track better the receipts and balances. Although CareSense is not the current rep payee , any funds at the home for individual #1 will be tracked accordingly and reconciled. All client funds for ind. #1 is reconciled. |
04/02/2021
| Implemented |
6400.112(g) | The asleep drill conducted on 5/6/20 was held at 4:45am. The asleep drill conducted on 11/2/20 was held at 4:45am. All drills must be held at different times of the day and night to satisfy regulation. | Fire drills shall be held on different days of the week and at different times of the day and night. | Retraining of the fire drill process occurred with the Program coordinator and assistant director - where the importance of varying the drills and having unplanned drills on different days of the week and different is important to the overall safety of all the individuals. |
04/02/2021
| Implemented |
6400.141(c)(3) | Physical was completed for Individual #1 on 3/3/21. The physical did not include documentation of the required immunizations. Tetanus (Td) is required every 10 years. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Per the ISP individual # 1 was given a tetanus booster on 2/17/2015 and would not be due for another shot until 2025. Her pcp is updating her physical to reflect this . |
04/28/2021
| Implemented |
6400.141(c)(10) | Physical was completed for Individual #1 on 3/3/21. The "Individual free from contagious disease" section was blank. Neither "Yes" or "No" boxes were checked, and no additional recommendation or specific instructions were made is the designated section. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | The physical was resubmitted to the PCP for individual #1 and the section was updated to reflect her current status of free from communicable disease. Lead staff retrained on medical appointments and what should be completed on a physical . |
04/23/2021
| Implemented |
6400.141(c)(11) | Physical was completed for Individual #1 on 3/3/21. The physical did not include documentation of the need for blood work at recommended intervals. | 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 physical was resubmitted to the PCP for individual #1 and the section was updated to reflect her bloodwork needs. Lead staff retrained on medical appointments and what should be completed on a physical . |
04/23/2021
| Implemented |
6400.142(a) | A dental visit occurred on 11/19/19, cleaning was not completed due to lack of cooperation. Return was to be in one year. A dental visit did not occur in 2020 through 3/31/2021. Annual dental exam and cleaning is required. | 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. | An updated special smiles dental consent form was completed and a new dental date has been requested from special smiles . staff retrained on the importance of medical appointments and due dates . |
04/30/2021
| Implemented |
6400.143(a) | Individual #1 refuses dental exams. No documentation of refusals or continued attempts to train Individual #1 about the need for health care was provided. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | Staff was retrained on the process , if the situation arises that individual #1 refuses dental exams or any other appointments.. |
04/02/2021
| Implemented |
6400.34(a) | Individual #1 rights were reviewed on 1/1/21. The review did not include all rights as outlined in § 6400.32. Rights of the individual.
(b) An individual has the right to civil and legal rights afforded by law, including the right to vote, speak freely, practice the religion of the individual's choice and practice no religion.
(c) An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.
(d) An individual shall be treated with dignity and respect.
(e) An individual has the right to make choices and accept risks.
(f) An individual has the right to refuse to participate in activities and services.
(g) An individual has the right to control the individual's own schedule and activities.
(i) An individual has the right of access to and security of the individual's possessions.
(j) An individual has the right to voice concerns about the services the individual receives.
(n) An individual has the right to unrestricted and private access to telecommunications.
(p) An individual has the right to choose persons with whom to share a bedroom.
(q) An individual has the right to furnish and decorate the individual's bedroom and the common areas of the home in accordance with § 6400.33 (relating to negotiation of choices).
(r) An individual has the right to lock the individual's bedroom door.
(1) Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door.
(2) Access to an individual's bedroom shall be provided only in a life-safety emergency or with the express permission of the individual for each incidence of access.
(3) Assistive technology shall be provided as needed to allow the individual to lock and unlock the door without assistance.
(4) The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency.
(5) Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door.
(s) An individual has the right to have a key, access card, keypad code or other entry mechanism to lock and unlock an entrance door of the home.
(1) Assistive technology shall be provided as needed to allow the individual to lock and unlock the door without assistance.
(2) The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency.
(3) Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door.
(t) An individual has the right to access food at any time.
(u) An individual has the right to make health care decisions. | 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. | Individual #1 was retrained on her rights to include all rights base on the regulation . The updated rights were reviewed with staff as well . |
04/23/2021
| Implemented |
6400.165(c) | Medications Administration Record (MAR) for Individual #1 recorded an entry for "Ergocalciferol 8,000 unit/ML Give 1 milliliter VIA J-TUBE once daily." The label on the Ergocalciferol was written as "Ergocalciferol 8.00 unit/ML Give 0.3 milliliters (2,400 units total) via tube once daily."
MAR for Individual #1 recorded an entry for "Clozapine 100mg tablet (generic for Clozaril)/EA take 1 tablet by mouth every morning and 4 tablets at bedtime." Staff #1 reported that they do not give the medication by mouth but rather crush all and give via J-Tube. | A prescription medication shall be administered as prescribed. | There was a med change and the new April MAR reflected the correct dose , which was .3 milliliters for Ergocalciferol . Staff was retrained on ensuring that the medication should be administered as prescribed |
04/02/2021
| Implemented |
6400.166(a)(2) | The March 2021 medication administration record for Individual #1 did not contain the name of the prescriber. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | The name of the prescriber has been updated for April 2021.
Staff was retrained on what to look for on a MAR , while doing checks , which includes the prescriber. |
04/23/2021
| Implemented |