| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | Individual #1's date of admission to the home was 1/30/23. Individual #1's 4/8/23 assessment and 6/2/23 Individual Support Plan (ISP) both state the individual has no concept of funds, requires total assistance to manage their money, frequently overdrafts their account, needs assistance with paying their cell phone bill, and needs a behavior support plan implemented due to their impulse control and over drafting money. Individual #1's ISP also states that as of 3/7/23 the provider agency, Care Sense Living LLC., is going to help the individual re-apply for Social Security Income (SSI) benefits as the previous attempt was denied. The individual needs total assistance with applying for SSI to obtain funds.
At the time of the 6/21/23 inspection, the home has never assisted Individual #1 with managing daily funds, paying their cell phone bill, and has not kept an up-to-date record of the personal possessions the individual as at their home.
During the 6/22/23 onsite inspection of the home, there were 9 unopened envelopes from PA ABLE, a financial account open in Individual #1's name. One financial ledger from PA ABLE was open and identified a large sum of money in the account. The individual was not assessed to be able to handle any amount of funds independently, but the home reports the individual is not receiving assistance with their PA ABLE financial account. The home reported to the Department they are not assisting the individual with opening their mail and this financial account or had knowledge of the information the individual's financial account was mailing them. It was reported that Individual #1 does not open mail and doesn't understand the concept of needing to open mail if there are financial matters that need addressed in a timely manner.
During the 6/22/23 onsite inspection there were two unopened pieces of mail from the individual's pharmacy, sent on 5/9/23 and 6/14/23. The home was unsure if these items were bills that need paid or receipts from purchases. Individual #1 is not receiving support from staff with these financial matters. | 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 7/13/23, staff were retraining on the importance of ensuring that 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. Director of Residential and other management team members created a task list and have been able to meet for scheduled planning meetings (7/17/23,7/19/2,7/21/23) to share info and gather information/documents (paychecks- giant Hershey/pa able / for individual # 1 social security re submission, which is scheduled to be resubmitted by 7/28/23. |
07/28/2023
| Not Implemented |
| 6400.22(d)(2) | Individual #1's date of admission to the home was 1/30/23. Individual #1's 4/8/23 assessment and 6/2/23 Individual Support Plan (ISP) both state the individual has no concept of funds, requires total assistance to manage their money, frequently overdrafts their account, needs assistance with paying their cell phone bill, and needs a behavior support plan implemented due to their impulse control and over drafting money. The individual stores receipts from purchases in an envelope hanging on the wall in the living room. The home does not have record of financial disbursements made to or for the individual, nor does it have a record of financial resources, including the dates and amounts of deposits and withdrawals made to or for the individual for their PA ABLE account or bank account. | (2) Disbursements made to or for the individual.
| On 7/13/23 staff were trained on the importance of managing Disbursements made to or for the individual. As of 7/25/23 a financial binder was established that has documentation of Indvidual PA able account and paychecks, and receipts. |
07/28/2023
| Not Implemented |
| 6400.67(a) | At the time of the 6/22/23 inspection, the cotton blind on Individual #1's bedroom window that faces the side of the home was broken and would not raise and lower. | Floors, walls, ceilings and other surfaces shall be in good repair. | The cotton blind was replaced as of 7/24/23. On 7/13/23-the staff were retrained on the importance of having floors walls and ceiling in good repair. Management staff including the lead staff, the director were retrained on providing oversight to the home regarding upkeep and repairs. Home compliance will be in the form of monthly House checks which include walk thru of the home to check for compliance. |
08/02/2023
| Implemented |
| 6400.68(b) | At the time of the 6/22/23 inspection, the water temperature in Individual's bathtub/shower combination measured 124.1 degrees Fahrenheit. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | As of 7/24/23 the hot water temperature was lowered and also tested for compliance on more than one occasion over a week period. On 7/13/23 staff were retrained on the importance of ensuring and testing the water temperature so that the Hot water temperatures in bathtubs and showers may not exceed 120°F. Management staff including the lead staff, the director were retrained on providing oversight to the home regarding hot water temps in the home. Home compliance will be in the form of monthly House checks which include walk thru of the home to check for compliance. |
08/04/2023
| Implemented |
| 6400.103 | During the 6/21/23 inspection, the agency, Care Sense Living LLC., produced an Emergency Evacuation Policy for the agency. This policy did not include the means of transportation to the emergency shelter location or the emergency shelter location the home is to use in the event of an emergency evacuation.
The home produced an Emergency Evacuation and Temporary Placement plan. This plan did not include the individual's responsibilities or applicable staff responsibilities. This plan states staff on shift are to contact a program coordinator for directions and the process of evacuation, can contact an on-call point person, and is to take further direction for delivery of medications, supplies, and notification of family members by the program coordinator or program specialist. The agency, Case Sense Living LLC., did not provide the Department with any staff member that holds the title of a program coordinator for the direct support staff to know who to contact for further instructions.
Both plans were missing components of the requirements defined in 55 Pa. Code § 6400.103. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| On 7/13/23 Staff person were updated on the updated emergency evacuation and temporary Placement protocol. The emergency evacuation and temporary Placement protocol were updated to reflect the missing components and they now include the means of transportation to the emergency shelter location or the emergency shelter location the home is to use in the event of an emergency evacuation. The Emergency Evacuation and Temporary Placement plan now includes the individual's responsibilities or applicable staff responsibilities. This plan has been updated who the staff and family members should contact in an emergency. Both plans updated to reflect all components of the requirements defined in 55 Pa. Code § 6400.103. |
07/13/2023
| Implemented |
| 6400.112(c) | The electronic fire drill records from January 2023 to June 2023 and paper fire drill records for May and June 2023 do not document if all smoke detectors in the home were operative during the time of the fire drills. At the time of the 6/22/23 inspection, the home was witnessed to be equipped with 5 smoke detectors and no records of additions or removal of smoke detectors within the home. During the listed months, anywhere from 3-6 smoke detectors were noted to be operative. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | On 7/13/23 staff were retrained on the importance of completing fire drills and all its components that need to be documented including the documentation of the monthly meeting place and the smoke detector used. During the home check for the month of July an accurate account of smoke detectors will be documented, and the fire drill form/system will be updated by 7/28/23. Lead staff and the director were both retrained on the importance of monitoring fire drills on a monthly basis and ensuring that it's completed in full and accurate. |
08/04/2023
| Implemented |
| 6400.112(h) | The electronic fire drill records from January 2023 to June 2023 and paper fire drill records for May and June 2023 do not document if Individual #1 went to the meeting place during the monthly fire drills. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | On 7/13/23 staff were retrained on the importance of completing fire drills and all its components that need to be documented including the documentation of the monthly meeting place and the smoke detector used and documentation on if the Indvidual's went to the meeting place. during the home check for the month of July an accurate account of smoke detectors will be documented, and the fire drill form/system will be updated by 7/28/23. Lead staff and the director were both retrained on the importance of monitoring fire drills on a monthly basis and ensuring that it's completed in full and accurate. |
08/04/2023
| Not Implemented |
| 6400.112(i) | The electronic fire drill records from January 2023 to June 2023 and paper fire drill records for May and June 2023 do not document or report if a smoke detector was activated to simulate the monthly fire drills. | A fire alarm or smoke detector shall be set off during each fire drill. | On 7/13/23 staff were retrained on the importance of completing fire drills and all its components that need to be documented including the documentation of the monthly meeting place and the smoke detector used and documentation on if the Indvidual's went to the meeting place. During the home check for the month of July an accurate account of smoke detectors will be documented, and the fire drill form/system will be updated by 7/28/23. Lead staff and the director were both retrained on the importance of monitoring fire drills on a monthly basis and ensuring that it's completed in full and accurate. |
08/04/2023
| Implemented |
| 6400.141(c)(1) | (Repeated Violation -- 6/21/22) Individual #1's 10/4/22 annual physical examination did not include a review of their medical history. There are two physical examination record documents completed by the physician on 10/4/22 in the individual's record. Both documents state a review of the individual medical history is attached, however, there is no medical history present. | The physical examination shall include: A review of previous medical history. | On 7/13/23 staff were retrained on the importance of ensuring that the physical examination shall include A review of previous medical history. |
07/13/2023
| Implemented |
| 6400.142(e) | On 2/2/23 Individual #1's dentist reported the individual has multiple decayed teeth, moderate bone loss, needs multiple teeth restored, and needs multiple teeth extracted. The dentist included a teeth chart with all their recommendations for extractions, crowns, restorations, and follow up work needed, and documents the individual needs caregivers to brush the individual's teeth with a goal of improving the individual's oral hygiene. At the time of the 6/21/23 inspection, there is no further documentation in the record that the home has scheduled or completed any follow up work or that they are working with Individual #1 to improve their dental hygiene. | Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed. | On 7/13/23 staff were trained on the importance of ensuring that Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed. |
07/13/2023
| Implemented |
| 6400.144 | (Repeated Violation -- 6/21/22) Individual #1's 10/4/22 physical examination record documents the individual has an appointment with ophthalmology. The individual's record states the individual had a vision appointment scheduled for 2/16/23 but it was rescheduled for 5/23/23. There are no records explaining why the appointment was not completed as scheduled on 2/26/23. | 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 7/13/23, staff were trained 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. Individual #1 got their glasses on 6/10/23. |
07/13/2023
| Not Implemented |
| 6400.145(1) | During the 6/21/23 inspection, the provider agency was only able to produce a Medical Emergencies and Emergency Medical Plan document. This document did not include the hospital or source of heath care the individuals in the home are to utilize in an emergency. | The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. | On 7/13/23 - Staff were trained on the importance of following the medical emergencies and emergency medical plan ad its updated components which includes the hospital or source of health care that will be used in an emergency. |
07/13/2023
| Implemented |
| 6400.145(3) | During the 6/21/23 inspection, the provider agency was only able to produce a Medical Emergencies and Emergency Medical Plan document. This document did not include the emergency staffing plan the home is to utilize in an emergency. | The home shall have a written emergency medical plan listing the following: An emergency staffing plan. | On 7/13/23 - Staff were trained on the importance of following the medical emergencies and emergency medical plan ad its updated components which includes the hospital or source of health care that will be used in an emergency as well as the staffing plan for the home shall have a written emergency medical plan listing the following: An emergency staffing plan. |
07/13/2023
| Implemented |
| 6400.172 | At the time of the 6/22/23 inspection there was very little food present in the home. The provider agency reported to the Department during the inspection that the home does not have any daily, weekly, or monthly menus prepared for the home or documentation to show that at least three meals were offered and available to Individual #1 daily.
The home did not produce documents that the individual's physician has ordered any food restrictions or other dietary needs, nor does the individual have a restrictive plan to restrict food. | At least three meals a day shall be available to the individuals.
| On 7/13/23 staff were retrained on the importance of ensuring that at least three meals a day shall be available to the individuals and that an individual has the right to access food at any time. The director of residential also set up as of 7/25/23 an online grocery store portal access so all team members have access to see food choices and purchases fixed onsite. the behavior support plan which identifies positive approaches will be reviewed annually and or as needed when identified or a new staff starts. |
07/25/2023
| Implemented |
| 6400.181(a) | Individual #1's date of admission is 1/30/23. The individual's initial assessment wasn't completed until 4/8/23, more than 60 days after their date of admission. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | The program specialist was retrained on 7/21/23 on their role and that they shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting and that Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. |
07/21/2023
| Not Implemented |
| 6400.181(d) | The author of Individual #1's 4/8/23 assessment did not sign or date the document. | The program specialist shall sign and date the assessment. | The program specialist was retrained on 7/21/23 on their role and that they shall provide, sign, and date the assessment. |
07/21/2023
| Implemented |
| 6400.181(e)(6) | Individual #1's 4/8/23 assessment does not include their ability to use and avoid poisonous substances. The assessment states the individual "does not mess with poisonous substances" and it's best practice they are locked up. | The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | The program specialist was retrained on 7/21/23 on their role and that they shall provide, sign, and date the assessment and that the assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. On 7/28/23 the assessment will be updated to reflect current poison status. |
07/28/2023
| Implemented |
| 6400.181(e)(10) | Individual #1's 4/8/23 assessment does not include their lifetime medical history. | The assessment must include the following information: A lifetime medical history. | The program specialist was retrained on 7/21/23 on their role and that the assessment must include the following information: A lifetime medical history. On 7/28/23 the assessment will be updated to reflect current poison status, and lifetime medical was added. |
07/28/2023
| Not Implemented |
| 6400.211(a) | Individual #1's basic information document in their record is used to capture all important and emergency information for the individual. This document lists the incorrect address that the individual resides at, in two different locations. The address listed on this document is not an active address for the state of Pennsylvania.
The home produced an emergency information and plan form for Individual #1 on 6/23/23. This record documented emergency contact persons and the individual's physician. This record was not located in the individual's record, not at their home, or produced for the Department when requested on 6/21/23 and 6/22/23. The emergency information produced also documents it was completed on 11/4/22 and Individual #1 did not enter the facility until 1/30/2023. There are no records that document who the individual's emergency contact person is after they started services with the agency. | Emergency information for an individual shall be easily accessible at the home.
| Staff were trained on the importance of ensuring Emergency information for an individual shall be easily accessible at the home. Individual #1 information has Emergency information for an individual shall be easily accessible at the home and will be updated on 7/28/23. |
07/28/2023
| Implemented |
| 6400.212(a) | Individual #1's dental hygiene plan on their basic information sheet within their record lists dental hygiene assistance needed for themselves and includes the needs of another individual. | A separate record shall be kept for each individual.
| On 7/13/23 -all staff were trained on the importance of keeping a dental hygiene plan that is solely for Individual #1. Their dental hygiene plan will be updated on 7/28/23. |
07/28/2023
| Implemented |
| 6400.212(b) | Individual #1's physical examination record was completed, signed, and dated by their physician on 10/4/22. The record states the individual's Tuberculin skin test was administered on 10/4/22, read on 10/6/22, and the results were negative. However, the results and the date the results were read were added to the physical examination record after the 10/4/22 physical examination. The person making the additions to the record and the date they were added was not documented on the record. | Entries in an individual's record shall be legible, dated and signed by the person making the entry.
| 07/13/23 Staff were retrained on the importance of ensuring that pertaining to the physical Entries in an individual's record shall be legible, dated, and signed by the person making the entry. An updated copy of the physical was completed on 7/24/23. |
07/24/2023
| Implemented |
| 6400.216(a) | Individual #1's records were not locked in the home, and they were unattended during the 6/22/23 onsite inspection. The records found unlocked and their location in the home were: individual financial record documents in a bin in the living room, individual #1's mail on a shelf in the living room, and Individual #1's June 2023 medication administration record in a desk in the living room. | An individual's records shall be kept locked when unattended.
| Items were locked in the home for individual #1 as of 6/26/23. On 7/13/23 -Staff were retrained on the importance of keeping the individual's records shall be kept locked when unattended. |
07/25/2023
| Implemented |
| 6400.32(t) | During the 6/22/23 inspection of the home, very little food was in the home. The agency, Care Sense Living LLC., reported to the Department during the inspection, that the home does not have any daily, weekly, or monthly menus prepared for the home or documentation to show that at least three meals were offered and available to Individual #1 daily. The home reports Individual #1 is not involved in any meal or menu planning that affects the food offered to them and available to them in the home.
The home did not produce documents that the individual's physician has ordered any food restrictions or other dietary needs, nor does the individual have a restrictive plan to restrict food. | An individual has the right to access food at any time. | As of 7/25/23 -menus were created and the home shops weekly and or biweekly and the individual is a part of those choices. Since the inspection, food purchases have been made on more than one occasion. Food items were purchased for the home and food is available for the individual consumption. On 7/13/23, staff were retrained on the importance of ensuring that at least three meals a day shall be available to the individuals and that an individual has the right to access food at any time. The director of residential also set up as of 7/25/23 an online grocery store portal access so all team members have access to see food choices and purchases fixed onsite. |
07/25/2023
| Implemented |
| 6400.34(a) | (Repeated Violation -- 6/21/22) Individual #1's date of admission is 1/30/23. The individual's rights defined in 6400.32 were not reviewed with the individual until 1/31/23, after admission. Additionally, at the time of the 6/21/23 inspection the individual's rights defined in 55 Pa Code 6400.31 and 6400.33 were not reviewed with the individual. | 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. | On 7/13/23 - staff were retrained on the importance of ensuing that the home 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. |
07/13/2023
| Not Implemented |
| 6400.163(b) | During the 6/22/23 onsite inspection of the home, Individual #1's 30-day supply of Lisinopril was produced by the pharmacy in a pill packet that contained individually packed 5 mg pills. One of the pill pockets on the pack had medical tape over the back of the pill pocket, where the pill would be popped out. The container was visibly ripped where the pill had been initially popped out, then ripped again over the tape after something was popped out of the pocket again. The home did not have any records that any pills had needed to be disposed of since the individual's admission on 1/30/23. The pill from this pocket was removed from the original container prior to administration. | A prescription medication may not be removed from its original labeled container in advance of the scheduled administration, except for the purpose of packaging the medication for the individual to take with the individual to a community activity for administration the same day the medication is removed from its original container. | On 7/13/23 - staff were retrained on the importance of ensuing that A prescription medication may not be removed from its original labeled container in advance of the scheduled administration, except for the purpose of packaging the medication for the individual to take with the individual to a community activity for administration the same day the medication is removed from its original container. |
08/04/2023
| Implemented |
| 6400.166(a)(1) | Individual #1 is ordered Ibuprofen 200mg as needed for mild pain and assessed to be unable to self-administer medications. During the 6/22/23 onsite inspection at the home, this medication was in a 30-day supply pill packet container. One of these pill packet containers was dispensed from the pharmacy on 3/17/23 with 30 pills, and 9 pills were popped out of their individual pockets. Staff person #1 reported to the Department that Individual #1 takes the medication sometimes. The administration of these 9 pills is not recorded on Individual #1's Medication Administration Record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Individual's name. | On 7/13/23 - staff were retrained on the importance of ensuing that A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Individual's name. |
08/04/2023
| Not Implemented |
| 6400.166(a)(11) | (Repeated Violation -- 6/21/22) Individual #1's April and May 2023 Medication Administration Records do not include the diagnosis or purpose for Lisinopril. | 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. | MAR was updated as of 7/25/23 to list the diagnosis for Lisinopril. Staff were retrained on the importance. of keeping 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.in order to maintain compliance a MAR check will be conducted during the home checks the next of which is scheduled to be submitted 7/28/23 to the director of residential and then to the director of operations/CEO by 8/4/23 for review. |
08/04/2023
| Not Implemented |
| 6400.166(a)(13) | (Repeated Violation -- 6/21/22) The name and initials of the person who administered Lisinopril 5mg to Individual #1 at 8pm on February 3rd, 4th, 5th, 2023, April 1st, 2nd, 3rd, 5th, 14th, 15th, 2023, and May 8th and 14th, 2023, was not documented on the record. The initials of the person to administer the medications were logged on the records but the name of the staff person whom the initials correspond to, was not recorded to identify the name of the person who administered the medication. | 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. | On 7/13/23, Staff were retrained on the importance that 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. |
07/28/2023
| Implemented |
| 6400.167(a)(1) | (Repeated Violation -- 6/21/22) Individual #1's 3/7/23 Medication Administration Record does not document that the individual's Lisinopril 5mg was administered that day. There is a dark square around the box to complete if administered without documentation if the medication was administered, refused, missed, etc. | Medication errors include the following: Failure to administer a medication. | On 7/13/23 - staff were retrained on the importance of ensuring that they document and administer meds as prescribed and discussion included that Medication errors include the following: Failure to administer a medication. |
08/04/2023
| Not Implemented |
| 6400.167(c) | The medication error described in 6400.167a1 was not reported in the Department's incident management system. | A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). | On 7/13/23 - staff were retrained on the importance of ensuring that A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). medication error was inputted. |
07/13/2023
| Not Implemented |
| 6400.186 | Individual #1's Individual Support Plan (ISP) states the individual needs assistance to ensure they are being safe using social media and safe from exploitation on social media. The ISP states the individual has a cell phone, an iPod and iPad. The home is not assisting the individual with social media use. The individual does not have any plans created by the agency to ensure they are being safe and not exploited and the agency is not aware of the individual's social media interactions and devices they use.
Individual #1's ISP states the individual can be unsupervised in their bedroom with 15-minute checks from staff. There are no records that staff are monitoring the individual per the plan.
Individual #1's ISP states they require assistance with all daily living skills. This includes opening and accessing the individual's mail. It was reported that Individual #1 does not open mail and doesn't understand the concept of needing to open mail if there are financial matters that need addressed in a timely manner. At the time of the 6/22/23 inspection, there were 9 unopened envelopes from PA ABLE, a financial account open in Individual #1's name, and two unopened pieces of mail from the individual's pharmacy, sent on 5/9/23 and 6/14/23. The home was unsure if these items were bills that need paid or receipts from purchases. The home reported to the Department they are not assisting the individual with opening their mail. | The home shall implement the individual plan, including revisions. | On 7/13/23, staff were retrained on the importance of ensuring that the individual #1 plan is being implemented as follows including checking on them as it pertains to social media (Facebook) since they can be vulnerable to be taken advantage of. |
07/28/2023
| Implemented |
| 6400.195(a) | Individual #1's 4/8/23 assessment states the staff will utilize the child safety locks in the vehicle when they are transporting the individual for an additional safety measure. The individual's plans and record do not include a component addressing the restriction or approval of the restriction by the human rights team prior to implementation. | For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures. | On 7/13/23, the staff were retrained on the importance of when applicable maintaining for each individual for whom a restrictive procedure may be used. The individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures. The director of operations spoke with the support's coordinator notifying them of child safety locks being in the ISP under traffic safety and as discussed. They will update it since the individual does not need child safety locks and this was an error a follow up email will be sent on 7/26/23 to confirm update. |
07/26/2023
| Implemented |
| 6400.213(1)(i) | Individual #1's record includes two dated photographs. Both photographs are the exact same photo. However, the date recorded on one is 1/6/23 and the other is 4/10/23. The date the photograph was taken is unknown. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number; current, dated photograph. | Updated photograph was taken by 7/25/23 and the records were updated to reflect this. On 7/13/23 staff were retrained on making sure that each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number; current, dated photograph. |
07/25/2023
| Not Implemented |
| 6400.213(1)(i) | Individual #1's record does not document if they have any next of kin. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number, next of kin. | As of 7/25/23, the individuals record was updated to reflect their next of kin. Staff were retrained on ensuring that Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number, next of kin. |
07/25/2023
| Not Implemented |