| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | Review of Individual #1's finances over the last 6 months show significant spending of the individual's personal spending money and food stamps to purchase food and household items. Review of Individual #1's room and board contract shows that individual's food shall be included in the room and board rate. Individual funds shall only be used for the individual's benefit. Upon inspection, licensing rep was informed that the individual chooses to purchase items that are not included in her diet plan (ie, chips, soda, juices) further review of receipts showed purchases of chicken, beef, yogurt, fruits, bottled water, sugar free kool-aid, and multiple other meal items. Individual also purchased a 7 inch strainer, dish towels, cleaning products, hot pads and a fan.
Additionally, it appears that on more than one occasion Individual #1 purchased meals and beverages while out in the community for the staff accompanying her. | Individual funds and property shall be used for the individual's benefit. | All staff are retrained. Moving forward it is implemented that a healthy diet menu will be drawn by the individual with her staff assistance. A money ledger has been implemented to track the individual purchases and items purchase on the receipt. A financial policy has been implemented for staff to read, sign and follow it when caring for the individual. See attached policy for the used of individual funds for their benefit, money ledger and sample healthy menu emailed to Kristen. |
02/04/2021
| Implemented |
| 6400.62(a) | Based on the Individual #1's assessment, ISP and staff interviews, Individual #1 is not safe with poisons. Upon site inspection, a bag of rock salt was located at the bottom of the steps leading to the basement, open and unlocked. Additionally there was dish soap out on the sink (inspector was informed that the soap was out because the individual was not home). There was also a can of Glade air spray located on the back of the toilet. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Rock Salt is now locked in the storage room in the basement including all poisonous materials. Moving forward quality assurance will make around weekly to make sure all poisonous materials are locked. See attached picture of storage room with locked poisonous materials emailed to Kristen. |
01/17/2021
| Implemented |
| 6400.67(a) | The left arm of the full size couch in the living room was not in good repair and had a significant amount of peeling and wear. | Floors, walls, ceilings and other surfaces shall be in good repair. | Couch is now replaced. Moving forward it is implemented that quality assurance will add house hold furniture check as part of his rounds. see attached picture of a new couch emailed to Kristen. |
02/08/2021
| Implemented |
| 6400.106 | Furnace inspection provided at time of inspection did not include an inspection date, only a next service date of September 2020. CEO relayed to licensing rep that furnaces were unable to be inspected due to COVID and will be inspected January of 2021. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| Furnace was not inspected in a timely manner due to Covid-19. Now furnace inspection is done. see attached Furnace inspection done on 1/17/2021 emailed to Kristen. |
01/17/2021
| Implemented |
| 6400.112(a) | Fire drills reviewed for the 2020 calendar year. While drills were recorded for each month, it is clear that the drills for the months of June 2020, July 2020, and August 2020 were photocopied. The date and time of the drill were changed, however, the evacuation time, exit, and individual prompts remained the same. | An unannounced fire drill shall be held at least once a month. | Staff was retrained. Moving forward agency have updated fire drill form with quality assurance personnel signature to signed off on proper conduction of fire drill. See attached new updated form emailed to Kristen. |
01/15/2021
| Implemented |
| 6400.181(e)(6) | Individual #1's assessment does include an area to evaluate the individual's ability to safely use or avoid poisonous materials, however, the assessment contradicts itself. Under the "Heath and Safety/Medications/Poisonous Materials/Heat and Fire Safety" section of the assessment, #63: Ability to safely use or avoid poisonous materials (poisonous materials may be kept unlocked if all individuals living int the home are able to safely use or avoid poisonous materials) states "the individual is unaware of the dangers of poisonous materials". #66: Poison Material Safety states "avoids poisonous materials". | The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | staff was retrained. The individual assessment was reviewed and corrected. Moving forward program specialist will supervised the house supervisor in completing individual assessment. see attached new correction of contradiction and staff training signed off emailed to Kristen. |
01/19/2021
| Implemented |
| 6400.32(r) | At the time of inspection, Individual #1 did not have a lock on her bedroom door. No documentation of the individual's refusal of the right to have a locking door or team meeting to discuss safety reasons for removing the right were found in the ISP or assessment. | An individual has the right to lock the individual's bedroom door. | The team meet with the individual, the choice of bedroom door lock was offered to the individual. she agreed on having a lock in her bedroom. lock was placed.. Moving forward agency will check on 6400 Regulation regularly. See attached picture of bedroom door lock emailed to Kristen. |
02/05/2021
| Implemented |
| 6400.34(a) | Individual rights signed by Individual #1 and additional rights provided to licensing representatives as part of the annual inspection do not reflect changes to individual rights included in the updated 6100 regulations. | 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. | Updated Individual rights is obtained and explained to the individual. she signed and it's placed on her file. moving forward agency will check on 6400 regulation regularly. see attached updated individual rights emailed to Kristen. |
01/15/2021
| Implemented |
| 6400.34(b) | Individual rights have not been signed by Individual #1 since admission (June 2019). This exceeds the timeframe of the home's responsibility to inform the individual of their rights annually. | The home shall keep a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights. | new updated individual rights are now signed by the individual .moving forward the program specialist has added annual individual's right signature on her to do Calendar. See attached updated signed rights emailed to Kristen. |
01/15/2021
| Implemented |
| 6400.46(d) | Staff #1 was initially certified in CPR on 6/17/18 and then not again until 12/2/20, exceeding the requirement for recertification. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Agency thought CPR recertification is every two years as per the American Red cross. moving forward quality assurance has developed a spread sheet to keep track of CPR re-certification. See attached spread sheet to keep track of recertification emailed to Kristen |
02/05/2021
| Implemented |
| 6400.52(c)(1) | Staff training records for Staff #1 do not include training for the safe and appropriate use of behavior supports. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Staff was trained. Moving forward behavioral support training has been included in the orientation training package. See attached training signed off emailed to Kristen. |
02/03/2021
| Implemented |
| 6400.52(c)(5) | Staff training records for Staff #1 do not include training for the safe and appropriate use of behavior supports. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | Staff was trained. Moving forward behavior supports training has been included in the orientation training packet .See attached training signed off emailed to Kristen. |
02/03/2021
| Implemented |
| 6400.163(a) | Individual #1 is prescribed Fungi Cure Liquid to be applied to both big toenails at 8am. At the time of the inspection there was no label on the bottle of medication. Licensing rep was informed that the box the bottle of Fungi Cure comes in may have been discarded. Medications are to be kept in their original labeled containers. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | Staff was retrained. Quality assurance person has obtained label for the Fungi Cure liquid. Moving forward it was implemented that audit will be done by quality assurance every week. See attached picture label of fungi liquid emailed to Kristen. |
01/13/2021
| Implemented |
| 6400.165(c) | Individual #1 has a PRN for Tylenol. At the time of inspection, there was no Tylenol in the home. Due to the medication not being in the home, it is unclear if the medication has been administered as prescribed. | A prescription medication shall be administered as prescribed. | Site superior called Pharmacy for refilled and the Tylenol was refilled and delivered. Moving forward it was implemented that quality assurance will audit PRN medication every week . See attached picture of Tylenol that was delivered emailed to Kristen. |
01/13/2021
| Implemented |
| 6400.165(g) | Individual # 1 is prescribed medication to treat psychiatric illness, review of documentation indicates individual only met with a licensed physician to review medication two times in the last year. 2/19/20 and 10/21/20, exceeding the requirement for 3 month reviews. | 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. | It was due to Covid 19 the Md's where only doing virtual visit and they refused to have psych medication review faxed to their office. Moving forward it was implemented that every three months that Psychiatry medication review is due. site supervisor will take the psychiatry review forms to the doctor's office for proper review. |
01/19/2021
| Implemented |