Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.144 | All MAR's present and previous (09/2023 -- 11/2023) indicate that the individuals self-medicate, both individual's medication administration record show that the individuals are initialing and not by the person(s) administering the medication. (Individual 1 was interviewed and stated they does not know their medication(s) | 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.
| it is apparent that individual 1's skills may need to be reevaluated. We will discuss with the team in regard to changing the ISP to better reflect individual 1's current capabilities. This discussion occurred on 12/11/23 with individual 1's SC and it was determined by the team to change the ISP to reflect that they need meds to
be administered by trained staff. When new admissions occur with self-administering individuals the agency will complete a self-administering competence and assessment to ensure they can complete self-administration. This will be reviewed by management when doing onsite visits. [DIRECTED PLAN 2/26/2024] |
03/18/2024
| Not Implemented |
6400.190(c) | There is no documentation of recreational and social activities for all individuals housed in the residential homes Apt. A and Apt. B. (It was disclosed that individuals are not being taken out on any outings) | Documentation of recreational and social activities shall be kept in the individual¿s record.
| A record to document activities will be created. 2 activities will be scheduled immediately. |
12/16/2023
| Not Implemented |
6400.214(b) | The records in the home were outdated for individuals 1 and 2. ISPs and physicals were outdated. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| Prior management was unaware of the location of the physicals. The physicals are current and in compliance and are now located in the home. Current ISPs will be placed in the home as soon as current CEO regains access to HCSIS. |
12/04/2023
| Not Implemented |
6400.216(a) | Records for all individuals were unlocked in the home. | An individual's records shall be kept locked when unattended.
| Individual records were replaced to their normal location which is the locked medicine cabinet. |
12/31/2023
| Not Implemented |
6400.162(a) | Both units Apt. A and Apt B staff are administering medications. No verification was provided (staff stated no training was given) that medication administration training was completed or trained by a trainer. | A home whose staff persons or others are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication. | Previous management was allowing non-trained staff to deliver medications occasionally. On the date of the unannounced visit, there was a medication trained staff member, but his credentials could not be verified by licensing because management did not know where they were physically located. Once the current CEO resumed his role, these documents were provided to licensing and the county and were verified, so that this staff member is now providing meds for both A/B. |
12/31/2023
| Not Implemented |
6400.163(f) | Prescription medications that were stored in the refrigerator was kept in an unlocked container. | Prescription medications stored in a refrigerator shall be kept in an area or container that is locked. | Upon review of the container, it was found to be not functioning properly, therefore a new container was purchased and put in its place. Medication will be stored in the new locked container. |
12/04/2023
| Not Implemented |
6400.182(c) | The ISP is not being revised annually and revised as needed when changes are made to the assessments for individuals 1 and 2. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | While the ISP is updated in the annual meetings, an outdated ISP was on the premises at the time of inspection. This will be fixed by the CEO placing a current ISP in the home. |
12/05/2023
| Not Implemented |