| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The home's self-assessment completed on 8/31/23, was not conducted either within 3-6 months of the current license's expiration date or within 6-9 months following the last annual inspection by the Department. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| The program Specialist prepared a log on 9/25/2023 showing home address, Certificate of compliance date and Due date for Self-Assessment to monitor compliance. |
09/25/2023
| Implemented |
| 6400.111(f) | On 9/21/23, the apartment's only fire extinguisher located in the kitchen was observed with an expired service tag of July 2022. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | A new fire extinguisher was taken to the home on September 22, 2023. The expiry date on the new fire extinguisher is December 2023. |
10/11/2023
| Implemented |
| 6400.113(a) | Individual #1, date of admission 10/27/22, did not have fire safety training. | 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 CEO registered for the Fire Safety Train the Trainer course on 10/12/2023. Fire Safety Training for staff and individual #1 is scheduled on 10/20/2023. |
10/25/2023
| Not Implemented |
| 6400.141(a) | Individual #1, date of admission 10/27/22, did not have a physical examination. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #1 conducted a wellness examination with his PCP on 5/4/2023. The previous Physical conducted prior to admission was done on 4/13/2022. Solidarity shall submit a copy of the Physical examinations done on 4/13/2022 and 5/4/2023. |
09/21/2023
| Implemented |
| 6400.141(c)(6) | Individual #1, date of admission 10/27/22, did not have a tuberculosis testing of any kind demonstrating negative results. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Individual #1 had tuberculosis testing with a negative result on 10/18/2022 prior to admission on 10/27/2022. |
09/21/2023
| Implemented |
| 6400.141(c)(9) | Individual #1, date-of-birth is 4/22/63, did not have a prostate screening or a physician's exemption from such an exam. | The physical examination shall include: A prostate examination for men 40 years of age or older. | Individual #1 had prostrate screening with a negative result on 5/4/2023. See result of prostrate exam by PCP on 5/4/2023 attached (Page 7) The next prostrate exam is due May 13, 2025. |
09/21/2023
| Implemented |
| 6400.142(a) | Individual #1's date-of-birth is 4/22/63, and admission date is 10/27/22. Their record did not include a dental examination. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Individual #1 had indicated upon admission that he did not want to see a dentist. He had his annual ISP meeting on October 4, 2023, and still insisted that he is not ready to see a dentist at this time. Since the ISP has not been updated to reflect the current annual ISP meeting of October 4, 2023, Individual #1 has signed a document dated 10/9/2023 indicating that he is dental hygiene independent and not ready to see a Dentist. Solidarity shall submit a copy of the signed document. |
10/10/2023
| Implemented |
| 6400.142(g) | Individual #1's 12/15/22 assessment indicates that they require extensive assistance with hygiene. The referenced assessment uses the term "hygiene" generally and does not specify any particular areas. Therefore, Individual #1 is determined to be dental-hygiene dependent. Their record did not include a dental hygiene plan. | A dental hygiene plan shall be rewritten at least annually. | Individual #1 had indicated upon admission that he did not want to see a dentist. He had his annual ISP meeting on October 4, 2023, and still insisted that he is not ready to see a dentist at this time. Since the ISP has not been updated to reflect the current annual ISP meeting of October 4, 2023, Individual #1 has signed a document dated 10/9/2023 indicating that he is not ready to see a Dentist. Solidarity shall submit a copy of the signed document. |
10/10/2023
| Implemented |
| 6400.20(b) | The agency did not complete a quarterly incident review and trend analysis for any of its homes. | The home shall review and analyze incidents and conduct and document a trend analysis at least every 3 months. | The CEO has developed a log on 10/9/2023 to monitor quarterly incident review. The CEO shall complete a quarterly incident review for Q3 2023 for all the homes by October 28, 2023. |
10/28/2023
| Implemented |
| 6400.165(g) | Indivudal#1's admission date is 10/27/22, and they have been prescribed psychotropic medication since then to present day. Their record does not include any 3-month medication 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. | The Program Specialist obtained psychotropic medication review done by the Psychiatrist on 7/28/2023. Attached. |
10/10/2023
| Implemented |
| 6400.166(b) | On 9/21/23, Individual #1's September 2023 Medication Administration Record did not contain the initials of the person who had administered the prescribed Prazosin 1 MG Cap. on 9/19/23 at 8:00 PM. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The Medication Administration Trainer organized a meeting on 10/11/2023 to discuss issues relating to medication Administration including the need to ensure that all information to be included in the Medication Administration Record (MAR) as prescribed in 6400.166 are completed. |
10/11/2023
| Not Implemented |
| 6400.213(1)(i) | Individual #1's record did not address their date-of-admission. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Individual #1¿s record was updated on 9/23/2023 to include the date of admission. |
10/10/2023
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not address their religious preference. | Each individual's record must include the following information: Personal information, including: (iv) Religious preference. | Individual #1¿s record was updated on 9/23/2023 to include the religious preference. |
10/10/2023
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not address their height, weight, eye color, hair color, and identifying marks. | Each individual's record must include the following information: Personal information, including: (ii) Race, height, weight, hair color, eye color, and identifying marks. | Individual #1¿s record was updated on 9/23/2023 to include race, height, weight, color of hair, color of eyes and identifying marks. |
10/10/2023
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not address their primary language of communication. | Each individual's record must include the following information: Personal information, including: (iii) Primary means of communication. | Individual #1¿s record was updated on 9/23/2023 to include primary language of communication. |
10/10/2023
| Implemented |