| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | A used approximate ½ bar of soap was located on the shelf behind the mirror in the bathroom. Clean and sanitary conditions shall be maintained in the home. | Clean and sanitary conditions shall be maintained in the home. | The shelf behind the mirror in the bathroom is now clean and in sanitary conditions by the home supervisor. |
12/22/2022
| Implemented |
| 6400.67(a) | The top shelf located on the door of the refrigerator was cracked and broken in the middle. Floors, walls, ceilings and other surfaces shall be in good repair. | Floors, walls, ceilings and other surfaces shall be in good repair. | A new refrigerator was Purchased. |
12/27/2022
| Implemented |
| 6400.141(c)(14) | Individual #42s physical examination dated 7/15/22 for the date of the exam and dated by the physician as 8/19/22 did not include their medical information pertinent to diagnosis and treatment in case of an emergency as this section of the physical examination was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | A Letter was sent to the doctor to advised him of the importance to making sure all areas of the physical are completed. Including medical Information pertinent to diagnosis and treatment. See attached letter email to Kristen |
12/22/2022
| Implemented |
| 6400.181(e)(3)(ii) | Individual #1's assessment dated 9/23/22 did not include the individual's progress over the last 365 calendar days for their communication skills. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Communication. | The assessment is now corrected to reflect progress in communication skills for the last calendar year. staff retrained.
please, see correction attached emailed to Kristen. |
12/27/2022
| Implemented |
| 6400.181(e)(10) | Individual #1 assessment dated 9/20/22 and Individual #2 assessment dated 10/25/22 did not include their lifetime medical history. | The assessment must include the following information: A lifetime medical history. | The agency has corrected this by attaching the lifetime medical behind the assessment. see attached email of corrected version email to Kristen. |
12/22/2022
| Implemented |
| 6400.181(e)(13)(i) | Individual #1's assessment dated 9/23/22 did not include the individual's progress over the last 365 calendar days in the area health. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| The assessment is now corrected with individual's progress in the health area in the last 365 calendar days.
see attached email with correction email to Kristen |
12/27/2022
| Implemented |
| 6400.181(e)(13)(iv) | Individual #3's assessment dated 9/23/22 did not include the individual's progress over the last 365 calendar days in the area of personal adjustment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | The agency has corrected the assessment and include progress in the area of health over the last 365 calendar days. see attached correction email to Kristen. |
12/27/2022
| Implemented |
| 6400.181(e)(13)(v) | Individual #3's assessment dated 9/23/22 did not include the individual's progress over the last 365 calendar days in the area of socialization. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | The agency has corrected the assessment and include individual progress in the area of socialization over the last 365 calendar days. see attached email to Kristen. |
12/27/2022
| Implemented |
| 6400.181(e)(13)(vi) | Individual #1's assessment dated 9/23/22 did not include the individual's progress over the last 365 calendar days in the area of recreation. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | The agency has corrected the assessment to include progress in the area of recreation over the last 365 Calendar days. See attached correction email to Kristen. |
12/27/2022
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's assessment dated 9/23/22 did not include the individual's progress over the last 365 calendar days in the area of financial independence. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| The agency has corrected the assessment to include individual's progress in the area of financial independence over the last 365 calendar days. See attached correction emailed to Kristen. |
12/27/2022
| Implemented |
| 6400.181(e)(13)(ix) | Individual #1's assessment dated 9/23/22 did not include the individual's progress over the last 365 calendar days in the area of community integration. | The assessment must include the following information: The Individual's progress over the last 365 calendar days and current level in the following areas: Community Integration | The agency has corrected this assessment to include the individual progress in the area of community Integration . see attached email correction to Kristen. |
12/27/2022
| Implemented |
| 6400.165(c) | Individual #2 is prescribed Natural Fiber Powder, 1TSP (5ML) w 8oz of liquid & drink by mouth up to 3x daily. The agency is administering the medication as a Pro re nata (PRN) however the administration directives are unclear. A prescription medication shall be administered as prescribed. | A prescription medication shall be administered as prescribed. | The agency has called the doctor's office and received a clear directive of the order and it was send to pharmacy. see Attached a copy of the clear directive from the doctor's office email to kristen. |
12/28/2022
| Implemented |
| 6400.165(g) | 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. The individual is prescribed medication to treat the symptoms of a diagnosed psychiatric illness. Individual #1 had a psychiatric medication review on 7/13/2022, then not again until 11/23/2022, which exceeds the three-month requirement. | 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. | The program director wrote a letter to the psychiatrist. Advising him of the importance of completion the 3 month Psych review in a timely manner. see letter to the Psychiatrist. see letter to the Psychiatrist attached email to Kristen. |
12/22/2022
| Implemented |
| 6400.169(a) | Staff # 1's annual medication practicum dated 7/5/22 did not include all of the appropriate course renewal requirements. Staff #1 had Medication Administration Observation completed on 7/5/22 and 7/6/22, and Medication Administration Record (MAR) review on 7/5/22 and 7.6.22. The Medication Administration Training Program renewal requirement is Two Medication Observations Completed within expected time frame in 1 year period (1 observation every 6 months), and Two MAR Reviews Completed within expected time frame in 1 year period (1 observation every 6 months). | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | The staff was retrained. The agency has corrected this : all staff are to complete one MAR review every 3 months. Then on the date of the second MAR review the first observation will be done as well. Then, 3 months Later the third MAR review. On the date of the fourth MAR review which will be six months away from the second MAR review, the second observation will be done. At this time bringing the staff to the end of the year with a completion 4 MAR reviews and @ observations six months apart. |
12/23/2022
| Implemented |