Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.77(b) | No scissors were located in the First Aid kit at time of inspection. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | The residential supervisor replaced the scissors in first aid kit per 6400.77 (b) regulatory guidelines. |
09/01/2021
| Implemented |
6400.111(a) | There was no Fire Extinguisher located in the kitchen (the extinguisher was in the dinning room). | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | An operable fire extinguisher with minimum 2-A rating was placed in the kitchen area of the site per 6400.111 (a) regulatory guidelines (see attachment #7) |
08/31/2021
| Implemented |
6400.141(c)(4) | It cannot be determined if on individual #1 1/6/21 physical examination that vision or hearing was reviewed or if further examination by a specialist, as this section was left blank. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | ARCC staff will ensure all pertinent information outlined on individual's physical form is completed by a physician at time of visit. |
09/01/2021
| Implemented |
6400.141(c)(7) | Individual #1 1/6/21 physical did not include a gynecological exam. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Individual #1 GYN exam is scheduled for 12/13/21 |
09/01/2021
| Implemented |
6400.141(c)(8) | Individual #1 1/6/21 physical did not include an annual mammogram exam. The last mammogram exam was conducted in 11/2019. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | Individual #1 received a mammogram on 3/3/21 (see attachment #9) |
08/31/2021
| Implemented |
6400.141(c)(13) | Individual #1 1/6/21 physical did not address special medication considerations or side effects. | The physical examination shall include: Allergies or contraindicated medications. | Individual #1 1/6/21 physical does address allergies per 6400.141(c)(13) regulatory guidelines (see attachment #12) |
08/31/2021
| Implemented |
6400.141(c)(14) | Individual #1 1/6/21 physical did not include medical information pertinent to diagnosis and treatment in case of emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | ARCC staff will ensure all pertinent information outlined on physical is completed by physician per 6400.141 (c)(14) |
08/31/2021
| Implemented |
6400.181(a) | Individual #1 initial assessment was completed 3/25/21, which is more than 60 days from their 12/29/20 admission date. There is also no assessment that has been completed within 1 year prior to 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 realized the error and was re-educated to ensure all initial assessments must be completed within 60 days of admission per 6400.181(a) regulatory guidelines. |
09/01/2021
| Implemented |
6400.181(e)(7) | Individual #1 knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources exceeding 120 degrees Fahrenheit is not adequately addressed on the 3/25/21 assessment. The assessment simply states that the individual avoids all heat sources. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | The program specialist corrected the assessment to give more details of Individual #1's awareness/knowledge of heat sources and the ability to sense and move away from heat sources exceeding 120 degrees Fahrenheit per 6400.181(e)(7) regulatory guidelines. (see attachment #10) |
09/01/2021
| Implemented |
6400.181(e)(12) | Individual #1 3/25/21 assessment does not address their recommendation for programming, as this section only references another person, Peter and speaks to him receiving behavioral therapy and having a behavior plan preventing him from certain activities. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The program specialist corrected the assessment to identify the programming needs of Individual#1 per 6400.181 (e)(12) per regulatory guidelines (see Attachment #11) |
09/01/2021
| Implemented |
6400.181(e)(13)(ix) | Individual #1 3/25/21 assessment does not address their progress and growth in the area of community integration. It only references another person, Peter who enjoys shooting hoops. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration. | The program specialist corrected the assessment to identify the community integration needs of Individual#1 per 6400.181 (e)(13)(ix) per regulatory guidelines (see Attachment #11) |
09/01/2021
| Implemented |
6400.32(r)(4) | Staff or individuals do not have access to the thermostat, which is locked. | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. | The residential supervisor made the thermostat locking mechanism accessible for the individual and staff person by having the key visible in the event of an emergency per 6400.32 (r)(4) regulatory guidelines. (see attachment #14) |
08/31/2021
| Implemented |
6400.34(a) | It cannot be determined if individual #1 was notified of their individual rights outlined in the 6400.32 regulations, as the signed copy of rights page provided shows that they signed off on being informed of the rights outlined under the 6100.181 and 6100.182 rights. | 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. | The program specialist reviewed Individual#1 Individual Rights outlined per 6400.34 (a) on 12/29/20 with Individual #1 and her family. (see attachment #15) |
08/31/2021
| Implemented |