Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.67(a) | The dining room chair had a loose seat and legs and screws were exposed, not in good repair. | Floors, walls, ceilings and other surfaces shall be in good repair. | We purchased the protection plan with this table and chair set which is good for 5 years. The repair person recommended an Allen wrench to tighten it regularly. |
01/06/2020
| Implemented |
6400.104 | A current and up to date letter to the local fire department notifying them the individuals who need assistance evacuating in the event of a fire was not provided during inspection. | 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.
| This letter was emailed to you (Brain) as requested. We were in compliance with this section and you asked that we email it to you by the following day. |
12/18/2019
| Implemented |
6400.113(a) | Fire safety training was not completed annually for individual 1. The last dated training was 4/3/18 | 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. | The fire safety training will be conducted annually and immediately filed in the corresponding individuals annual binder and checklist. |
12/20/2019
| Implemented |
6400.141(c)(10) | Physical exam dated 4/15/19 for individual 1 did not contain whether individual was free from communicable diseases in order to determine if any precautions need to be taken. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | The Agency Physical exam form has been updated to ask the question of whether the individual was free from communicable diseases. |
12/31/2019
| Implemented |
6400.141(c)(14) | Information pertinent to diagnosis in case of an emergency was not notated on the current physical examination form dated 4/15/19 for individual #1. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Our physical form was updated to reflect the pertinent diagnosis and emergency treatment. |
12/31/2019
| Implemented |
6400.181(d) | Program specialist did not sign and date the assessment dated 5/3/19 for individual 1. | The program specialist shall sign and date the assessment upon completion. The requirement to sign has been added to the binder checklist. | The Program Specialist will sign the completed assessment and file in the corresponding person's binder immediately. |
12/20/2019
| Implemented |
6400.34(a) | The Copy of Rights were not signed annually for individual 1, the last dated rights were signed 4/3/18 | 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 will file the Client Rights (Individual Rights) form immediately upon completion in the corresponding person's binder. |
01/01/2020
| Implemented |
6400.165(g) | Documentation of the 3 month psychotropic medication reviews were not in record for individual 1. Medications Divalproex and lorazepam .5mg were not reviewed by a licensed physician. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | All psychiatrist appointments will have a blank medical form as well as a blank 3 month medication review from (3 Month Psychotropic Review) for the doctor to complete for each appointment. Also, the policy 122 (medical appointments) was updated to include this information. |
01/22/2020
| Implemented |