Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.15(a) | The agency certificate of compliance expired 1/12/2022 and the self-assessment of the home was completed 2/09/2022. The self-assessment form used was last updated in 2018. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| The agency (CSL) conducted a retraining with the Director of residential and program specialist regarding the due dates of the self-assessment as well as the importance of completing Lii, which are due 3 to 6 months prior to the certificate of compliance expiration. During the training a new self-assessment was completed for each home to utilize as a sample moving forward. |
05/27/2022
| Not Implemented |
6400.110(e) | During the onsite inspection on 3/18/2022 the home which has three stories did not have interconnected smoke detectors. | 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 laketon home at the time of inspection had functioning smoke detectors but they were not interconnected. Interconnected smoke detectors were ordered and were delivered, a fire drill was completed in order to ensure that the new smoke detectors were functioning properly. staff were retrained on the 6400.110 ( e) regulation which indicates if a home is 3 or more stories it should have interconnected smoke detectors installed |
04/28/2022
| Implemented |
6400.111(f) | During the onsite inspection on 3/18/2022, the fire extinguisher located in the basement was last serviced in February 2021. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | Although the fire extinguishers were updated earlier that month, unfortunately the basement fire extinguisher was overlooked. ABC fire is scheduled to come out to check the fire extinguisher in the basement on 5/3/2022. Staff (direct care/ director of residential )were retrained on what is due annually as it pertains to the fire extinguisher being inspected by a fire safety expert annually |
04/28/2022
| Implemented |
6400.141(c)(4) | Individual #1 had a hearing screening completed 11/17/2020 and then again 1/05/2022. Individual #1's most recent vision screening was completed 1/06/2021. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | on individuals #1 physical did not include vison/hearing on physical and the doctor's office will complete the missing info on the physical by 5/9/22. Staff (lead staff - and director were retrained on the importance of managing medical appointments and follow ups and following doctors recommendations. |
05/30/2022
| Not Implemented |
6400.141(c)(14) | Individual #1's physical examination completed 7/20/2021 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | on individuals #1 physical did not include medical information on physical and the doctor's office will complete the missing info on the physical by 5/9/22. Staff (lead staff - and director were retrained on the importance of managing medical appointments and follow ups and following doctors recommendations. |
05/30/2022
| Not Implemented |
6400.142(a) | Individual #1, date of admission 11/19/2020, had an initial dental examination completed 12/28/21. | 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. | lead staff -and director of residential were retrained on the importance of managing medical appointments and follow ups and following doctors recommendations including dental appointment. A dental appointment for individual was made for June 5, 2022 @ 2pm |
06/05/2022
| Not Implemented |
6400.142(f) | Individual #1, date of admission 11/19/2020, does not have a written plan for dental hygiene nor has documentation in writing from the interdisciplinary team stating the individual has achieved dental hygiene independence. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | individual dental hygiene plan was updated on 3/23/2022 to reflect current status . Staff ( lead staff and director and program specilaist) were retrained on the need for a dental hygiene plan for each client and how to document progress and or completion via an interdisciplinary team meeting |
06/01/2022
| Not Implemented |
6400.143(a) | Individual #1, date of admission 11/19/2020, had scheduled an initial gynecological examination and pap smear for 2/25/2022. Individual #1 refused the appointment, but there was no documentation of any counseling provided to the individual. | 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. | individual #1 attended her Gyn appointment but still did not feel comfortable completing the entire exam. Staff, lead staff and direct care, were retrained on the importance of appointments and documenting refusals |
06/01/2022
| Not Implemented |
6400.18(a)(4) | Abuse incident #8935219 involving Individual #1 was discovered by the agency on 11/11/2021 and reported throught the Department's information management system on 11/16/2021. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Abuse, including abuse to a individual by another client.
| Staff (lead staff and director ) were retrained on the reporting process of incidents and the timelines for closing an incident 3/23/22. |
04/28/2022
| Implemented |
6400.18(b)(2) | On 3/6/2022, the agency discovered that Individual #1 did not have the prescribed Docusate Sodium 100mg administer on 3/6/2022 at 8:00am. This was not reported through the Department's information management system. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person:
A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner. | Staff (lead staff and director) were retrained on the reporting process of incidents and the timelines for closing an incident 3/23/22. Error was reported via EIM |
04/28/2022
| Not Implemented |
6400.163(h) | Individual #1 is prescribed Famotidine 20mg tablet, with instructions to take one tablet by mouth daily as needed for heartburn or reflux, with a use by date of 12/21/2021. The medication was administered to Individual #1 3/12/2022 and was present in the home during the inspection on 3/18/2022. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | The medication Famotidine was replaced due to it being expired. Staff (lead and director) were retrained on checking that medication is not expired within the home |
04/28/2022
| Implemented |
6400.165(c) | Individual #1 is prescribed Melatonin 3mg capsule, with instructions to take 3mg by mouth nightly as needed for sleep. The March 2022 medication administration record for Individual #1 documents individual refused the medication 3/02/2022, 3/04/2022,, 3/05/2022, 3/11/2022, 3/12/2022, and 3/16/2022, but this is to be administered only as needed. | A prescription medication shall be administered as prescribed. | The melatonin being listed was a documentation error and prior the staff used a electronic MAR which didn't always work accurately so caresense transitioned to a paper mar format. Staff ( lead and director ) were retrained on the step's for giving meds . |
04/28/2022
| Implemented |
6400.166(a)(11) | Individual #1's March 2022 medication record did not include diagnosis or purpose for the following medications: Haloperidol 5mg, Olanzapine 20mg, Clozapine 100mg, Benztropine Mesylate 1mg, Docusate Sodium 100mg, Hydroxyzine 50mg, Lithium Carbonate 150mg, Lithium Carbonate 300mg, Melatonin 3mg, Metformin Hydrochloride 500mg, and Famotidine 20mg. | 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. | Due to the documentation errors due to the electronic mar not always being functional, the Direct care staff and lead and lead staff and director of residential were retrained on the process of documentation and medication errors, giving medication and reporting medication issues as well as what needs to be included on a MAR. |
04/28/2022
| Implemented |
6400.166(a)(13) | Individual #1 is prescribed Hydroxyzine 50mg capsule, take 1 capsule by mouth 4 times a day. There is no record of administration on 3/1/2022, 3/8/2022, 3/13/2022 for the 3/16/2022 for the 12pm dose. On 3/10/22 the 12pm does was administered at 2:14pm. On 3/13/2022 the 4pm dose was administered at 5:34pm. On 3/16/2022 the 4pm dose was administered at 8:55pm. Individual #1 is prescribed Lithium Carbonate 150mg capsule, take 1 capsule by mouth daily, in the evening along with 300mg for a total of 450mg. There is no record of administration on 3/14/2022 for the 5pm administration. Individual #1 is prescribed Haloperidol 5mg, take 1 tablet by mouth 3 times a day. There is no record of administration on 3/01/2022 and 3/16/2022 for the 12pm dose. There is no record of administration on 3/01/2022, 3/06/2022, 3/08/2022, and 3/14/2022 for the 9pm dose. On 3/10/2022 the 12pm dose was administered at 2:04pm. | 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. | Due to the documentation errors due to the electronic mar not always being functional, the Direct care staff and lead and lead staff and director of residential were retrained on the process of documentation and medication errors, giving medication and reporting medication issues. |
04/28/2022
| Not Implemented |
6400.167(a)(1) | Individual #1 is prescribed Docusate Sodium 100mg capsule, with instructions to take one capsule by mouth two times a day. The agency failed to administered the medication to the individual on 3/06/2022 at 8:00am. The note on the 2022 medication administration record stated awaiting pharmacy refill. | Medication errors include the following: Failure to administer a medication. | Direct care staff and lead and lead staff and director of residential were retrained on the process of medication errors, giving medication and reporting medication issues as well as how to obtain approval form the doctor's office if a medication needs to be on hold. medication error was submitted in EIM. |
04/28/2022
| Not Implemented |