| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.104 | The home did not notify the local fire department in writing of the addresses of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Family Services United provided the state representative with an email notification and a fire letter for the new home, however the email to the fire department did not contain the address. This agency was informed by the state representative that the letter must be sent by certified mail which is not stated in the regulation. According to the regulation 6400.104 [The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.] Immediately, on 5/4/2021 the letter was resent to the fire department and included the address. |
05/04/2021
| Implemented |
| 6400.113(a) | Individual #1, date of admission 12/2/2020 was initially instructed in fire safety training on 12/9/2020. [Repeated violation 3/4/2020] | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | Individual #1 was admitted on 12/2/2021. This individual was trained in fire safety on 12/9/2021. According to regulation, 6400.113(a), [in the individual¿s primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home.] This violation occurred due to an ineffective admission process. To correct this deficiency, Family Services United (FSU) has revised the admission process by creating a checklist to designate specific management personnel to each item on the checklist and revising the program manager and program specialist job descriptions on 4/23/2021. |
04/23/2021
| Implemented |
| 6400.34(a) | Individual #1 was informed and explained individual rights on 12/2/2020. The rights document did not include the following rights: 6400.32b, an individual has the right to civil and legal rights afforded by law, including the right to vote, speak freely, practice the religion of his choice and practice no religion; 6400.32e, the right to make choices and accept risks; 6400.32g, to control his own schedule and activities; 6400.32j, the right to voice concerns about the services the individual receives; 6400.32k, the right to participate in the development and implementation of the individual plan; 6400.32L, the right to receive scheduled and unscheduled visitors, and to communicate and meet privately with whom the individual chooses, at any time; 6400.32p, the right to choose persons with whom to share a bedroom; 6400.32q, to furnish and decorate the Individual's bedroom and the common areas of the home; 6400.32r, to lock the individual's bedroom door; 6400.32s, to have a key, access card, keypad code or other entry mechanism to lock and unlock entrance door of the home; 6400.32t, to access food at any time; 6400.32u, to make health care decisions; 6400.32v, right may only be modified accordance with 6400.185. [Repeated violation 3/4/2020] | 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. | Family Services United (FSU) recognizes the importance of regulation 6400.34(a) [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.] As an agency we will ensure that individuals are educated on their rights per regulation. Individual #1 was informed and received explanation of individual rights on admission (12/2/2020), however, the FSU admission packet did not include the following rights: 6400.32(e), 6400.32(g), 6400.32(j), 6400.32(k), 6400.32(L), 6400.32(q) 6400.32(p), 6400.32(r), 6400.32(s), 6400.32(t), 6400.32(u), and 6400.32(v). The FSU admission packet was updated on 2/20/2021 to include all the rights listed above. Individual #1 and all other individuals residing at FSU signed the updated rights on 2/24/2021 in which the state representative received copies of signature pages for sample individuals via SharePoint. |
02/24/2021
| Implemented |
| 6400.166(a)(7) | Individual #1's April 2021 Medication Administration Report states "Lantus Solos Inj 100/ML; Inject 50 units subcutaneously every morning." The medication label states "inject 44 units subcutaneously every morning." | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | Individual #1 is on a titrating dose of Lantus insulin since 1/13/2021. The medication administration record (MAR) did not match the label. According to regulation 6400.166(a)(7) [A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.]. Immediately, on 4/23/2021 the agency contacted the physician to update the script to reflect the last order from 4/14/2021 which is on the MAR (Continue to increase Lantus to max of 65 units daily (0.5u/kg). Continue to increase by 2 units every 3 days until FBG < 150, max 65 units.) |
04/23/2021
| Implemented |
| 6400.166(d) | Individual #1's is prescribed Tylenol Extra Strength 500mg Caplets; take two caplets every six hours as needed for pain/fever. Individual #1 was administered this medication 8 times between 4/3/2021 and 4/17/2021. The medication was not available in the home on 4/22/2021 at 10:35AM. | The directions of the prescriber shall be followed. | Individual #1 had a PRN order of Tylenol on the medication administration record (MAR). The medication was not available in the home. According to regulation 6400.166(d) [The directions of the prescriber shall be followed.]. Immediately, on 4/26/2021 the medication was reordered and delivered to the home. |
04/26/2021
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not include identifying marks, color of eyes, color of hair, religious affiliation, next of kin, language and social security number. | Each individual's record must include the following information: Personal information | Individual #1 individual Data Form (IDF) was updated to include: identifying marks, color of eyes, color of hair, religious affiliation, next of kin, language and social security number on 4/23/2021. Residential Director reviewed to ensure that all other personal information is present and up to date on Individual #1 data form on 4/23/2021. |
04/23/2021
| Implemented |