| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(e) | There has not been a sleep drill conducted for this home in at least seven months (based on provided drills). | A fire drill shall be held during sleeping hours at least every 6 months. | Agency December 2022 fire drill will be held in the beginning of the month and that drill will be held during the night for this home. |
| Implemented |
| 6400.141(c)(14) | On the current physical for individual#1, information pertinent to diagnosis in the event of an emergency is blank; there should be information reported there, even if the recommendation is to call 911 | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Individual¿s #1 physical was reviewed and completed by Primary Care Physician (PCP). The physical form completed indicated information related to individual # 1 diagnosis. |
01/10/2023
| Implemented |
| 6400.141(c)(15) | Current physical does not include recommendations for diet or special instructions. | The physical examination shall include:Special instructions for the individual's diet. | Individual¿s # 1 physical was reviewed and completed by Primary Care Physician (PCP). The physical form completed indicated information related to Individual #1 dietary information. |
01/10/2023
| Implemented |
| 6400.181(e)(14) | Individual#1's assessment and ISP do not directly identify the individual's ability to swim. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | The Individual¿s Annual Assessment has been updated and the updated copy includes information about the individual¿s ability to swim. |
11/30/2022
| Implemented |
| 6400.165(b) | PRN Siltussin sa syp 100/5ml every 4 hours for individual#1, was not in home at inspection. Per staff nurse, (via phone), the pharmacy will fill as needed-explained it must be in the home unless discontinued. | A prescription order shall be kept current. | The Individual¿s Doctor was contacted and was able contact the Pharmacy to send the medication. The medication had been sent by the Pharmacy and now in the individual¿s med box. |
11/30/2022
| Implemented |
| 6400.165(c) | Medication artificial tears for individual#1 not administered as prescribed for the 4pm dosage 11/8/22, left blank on mar.
Give individual#1 170ml water flushes 3x's a day, 2, 11, 7. The November 7th and 8th flushes were not signed out for the 7pm flushes on both days. | A prescription medication shall be administered as prescribed. | The MAR was immediately corrected right after the licensing inspection. Agency Director of Operations completed a review of PA 15 Medication administration steps to ensure that medications are administered as prescribed by the individual's Doctors. |
11/30/2022
| Implemented |
| 6400.167(a)(1) | Medication artificial tears not administered for individual #1 as prescribed for the 4pm dosage 11/8/22, left blank on mar, this is a medication error.
Give individual#! 170ml water flushes 3x's a day, 2, 11, 7. The November 7th and 8th flushes were not signed out for the 7pm flushes on both days. This is a Medication error. | Medication errors include the following: Failure to administer a medication. | The MAR was immediately corrected right after the licensing inspection. Agency Director of Operations completed a review of the PA 15 Medication administration steps with the staff member on 11/10/2022 to ensure that medications are administered as prescribed at all times. |
11/30/2022
| Implemented |
| 6400.181(f) | The ISP meeting invitation is not dated; therefore, it cannot be ascertained if the notice was sent at least 30 days prior to the meeting date of 10/7/22 | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The individual¿s Support Coordination Team was immediately contacted after the licensing inspection to provide us a dated copy of the individual¿s ISP meeting invitation letter as the one they sent us was not dated and cannot ascertain if the notice was sent at least 30 days prior to the meeting date of 10/7/2022. A dated letter was sent to us and has been filed in the individual¿s book. A copy of the letter will be attached with all supporting documents. |
11/30/2022
| Implemented |