| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(b) | There was lint the size larger than a golf ball located in the dryer lint trap. | Floors, walls, ceilings and other surfaces shall be free of hazards. | A staff meeting was held for the residential sites through 9/14/22-9/21/22at 9:30am to address all citations and plans of corrections. On 9/14/22 the Residential Director also created a sign to ensure the lint is removed from the lint trap after every use was placed in the laundry room. Picture of sign and staff meeting notes are attached. |
09/26/2022
| Implemented |
| 6400.141(c)(6) | The annual physical exam did not have documentation that the individual #3 received a tetanus, diphtheria vaccine. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Individual #3 has been scheduled an appointment with the PCP for October 6, 2022 to obtain documentation on the tetanus, diphteria vaccine. The Program Specialist met with the direct support professionals of all residential homes (9/19-9/22) to ensure all employees are re-educated on the annual physical exam components. |
09/22/2022
| Implemented |
| 6400.141(c)(12) | Physical limitation Ind. # 3, section on the physical did not list where there were any physical limitations. | The physical examination shall include: Physical limitations of the individual. | Individual #3 has been scheduled an appointment with the PCP for October 6, 2022 to obtain information on physical limitations, if any. The Program Specialist met with the direct support professionals of all residential homes (9/19-9/22) to ensure all employees are re-educated on the annual physical exam components. |
09/22/2022
| Implemented |
| 6400.142(f) | The individual's #3 record did not have an updated written dental plan. | 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. | ARCC's Director wrote an updated Dental Hygiene Plan for Individual #3 on 9/16/22 (see attached signed Dental Hygiene Plan). |
09/16/2022
| Implemented |
| 6400.151(c)(2) | Physical Form dated 10/16/2020 did not address information of TB results or when the test was completed for staff #5. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | Physical for Staff #5 was completed on 10/22/2021. The Tb was placed on 10/26/21 and read on 10/28/21 (see attached). ARCC will ensure all current and completed physical exam forms are placed in the employee files. |
09/09/2022
| Implemented |
| 6400.181(a) | The record did not have an initial assessment, the individual #3 date of admission was 4/13/2022. | 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 initial assessment for individual #1 was created on 9/17/22. The assessment was sent to the team via email on 9/20/22. Attached is the initial assessment for individual and #1 and verification of being sent to the team. |
09/17/2022
| Implemented |
| 6400.181(e)(10) | The record did not include a lifetime medical history for Ind. #3. | The assessment must include the following information: A lifetime medical history. | On 9/22/22 The Director for ARCC developed a LTMH for Individual #3. See attached Lifetime Medical History. |
09/23/2022
| Implemented |
| 6400.46(b) | Agency did not provide verification that staff #5 was trained by a Fire Safety Expert. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Staff #5 reviewed training by a Fire Safety Expert (Tri-State) does not expire until 11/30/22. The training was sent to the auditor however, it was late. ARCC will ensure all training records, sign in sheets, and certificates are placed in the employee file upon receipt. ARCC will ensure all information pertaining to staff qualification and regulatory standard is accessible. (see attached training) |
09/16/2022
| Not Implemented |
| 6400.165(b) | Medication ACETAMINOPHEN Tab 500mg was in individual's #3 med box but not on the MAR, | A prescription order shall be kept current. | Medication Acetaminophen tab 500 mg was added to the MAR on 9/2/22. During the staff meeting which occured (9/14/22-9/22/22) ARCC discussed Medication Administration, Medication Administration Record, the 5 rights, and ensuring all prescribed medication matches the MAR. (See attached Agenda) |
09/02/2022
| Implemented |
| 6400.165(c) | Individual #3's Medication LAMOTRIGINE Tab 150mg was not logged as administered on 8/26/22 at 8pm dose.
Individual #3's Medication QUETIAPINE 400mg was not logged as administered on 8/26/22 for 8pm dosage
Individual #3's Medication GABAPENTIN 400mg 2pm and 8pm dose was not logged as administered on 8/26/22 | A prescription medication shall be administered as prescribed. | During the staff meeting which occurred (9/14/22-9/22/22) ARCC staff were retrained on Medication Administration, Medication Administration Record, documentation of medication errors, the 5 rights, and ensuring all prescribed medication matches the MAR. (See attached Agenda) |
09/22/2022
| Not Implemented |
| 6400.169(a) | Medication Administration Training not provided at time of inspection for staff #5 | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | Staff #5 completed the medication administration training on January 24, 2022. ARCC failed to ensure all documentation was provided at time of inspection Thus has appointment the Director to be responsible for the coordination of all internal and external audits. All staff training will be placed immediately into the staff training file. |
09/13/2022
| Not Implemented |
| 6400.195(b) | The record for Ind. #3 did not include an updated behavior support at the time of the review. | The behavior support component of the individual plan shall be reviewed and revised as necessary by the human rights team, according to the time frame established by the team, not to exceed 6 months between reviews. | ARCC identified a new Behavior Specialist for Individual #3. A meeting occurred on 9/21/22 with Individuals #3 new Behavior Specialist. During the meeting ARCC Program Specialist informed the new BS that a BSP will need to be submitted within the nest 30 days for the individuals after the initial assessment is conducted. |
09/21/2022
| Implemented |