| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The home's self-assessment, completed on 7/11/23, 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.
| Self assessment shall be completed 3-6 months prior to expiration date of agency COC. |
08/21/2023
| Implemented |
| 6400.68(b) | On 7/19/23, the hot water temperature of the bathtub in the bathroom located in the bedroom hallway measured 124.3°F at 12:19 PM. [Repeated Violation---11/9/21, 10/4/22, et al] | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Hot water temp shall not exceed 120 degrees |
08/21/2023
| Implemented |
| 6400.112(a) | According to the written fire drill record submitted from November 2022 to July 2023, only one drill, which was held on 7/11/23, was conducted during sleeping hours. | An unannounced fire drill shall be held at least once a month. | An unannounced fire drill shall be held at least once a month |
08/21/2023
| Implemented |
| 6400.141(c)(11) | Individual #1's physical examination completed on 7/18/23 did not include an assessment of their health maintenance needs, medication regimen, and the need for bloodwork at recommended intervals. This section was left blank. [Repeated Violation---10/4/22, et al] | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | Physical exam shall include health maintenance needs and the need for blood work |
08/21/2023
| Implemented |
| 6400.141(c)(15) | Individual #1's physical examination completed on 7/18/23 did not include special instructions for their diet. This section was left blank. | The physical examination shall include:Special instructions for the individual's diet. | Physical exam shall include individual diet |
08/21/2023
| Implemented |
| 6400.181(a) | Individual #1's admission date is 9/9/22. Their record did not include completion of an initial assessment. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Each individual shall have initial assessment within one year prior to or 60 calendar days after admission to the residential home. |
08/21/2023
| Implemented |
| 6400.15(b) | The agency used the Self-Inspection and Declaration Tool to measure and record compliance at the home on 7/11/23 instead of the Department's Licensing Inspection Instrument. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | The agency shall use the dept of licensing inspection instrument of the community homes for individual with IDD |
08/21/2023
| Implemented |
| 6400.18(a)(3) | EIM Incident #: 9155538 for a behavioral health crisis involving a facility-based response was discovered on 1/20/23 at 6:15 PM and reported on 1/22/23 at 3:50 PM. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Inpatient admission to a hospital.
| The home shall report the following incidents within 24 hours of discovery by a staff person. |
08/21/2023
| Implemented |
| 6400.18(a)(8) | EIM Incident #: 9229497 involving law enforcement activity was discovered on 6/8/23 at 10:45 AM and reported on 6/9/23 at 1:32 PM. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Law enforcement activity that occurs during the provision of a service or for which an individual is the subject of a law enforcement investigation that may lead to criminal charges against the individual.
| The home shall report the following incidents within 24 hours of discovery by a staff person. |
08/21/2023
| Implemented |
| 6400.165(g) | Individual #1 is prescribed psychotropic medication. They had a 3-month medication review completed on 1/19/23 that did not identify the medication reviewed, the reason for it being prescribed, the need to continue taking it, and the necessary dosage. [Repeated Violation---10/4/22, et al] | 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. | If a med is prescribed to treat symptoms of psych illness there shall be a review by a licensed physician every 3 months that includes the reason for prescribing the med. |
08/21/2023
| Implemented |
| 6400.166(a)(4) | On 7/19/23, Individual #1's prescribed pro re nata medication, Acetaminophen Tab. 325 MG---Take 1 tablet by mouth every four hours as needed for right leg pain---was found at the home. However, this medication was not named on their July 2023 Medication Administration Record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | The MAR shall include the name of medication |
08/21/2023
| Implemented |
| 6400.166(a)(9) | On 7/19/23, Individual #1's prescribed pro re nata medication, Acetaminophen Tab. 325 MG---Take 1 tablet by mouth every four hours as needed for right leg pain---was found at the home. However, the frequency of administering this medication was not recorded on their July 2023 Medication Administration Record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | A MAR shall have the frequency of administration. |
08/21/2023
| Implemented |
| 6400.166(a)(11) | On 7/19/23, Individual #1's prescribed pro re nata medication, Acetaminophen Tab. 325 MG---Take 1 tablet by mouth every four hours as needed for right leg pain---was found at the home. However, the purpose or diagnosis for this medication was not recorded on their July 2023 Medication Administration Record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | A Mar shall be kept with diagnosis including PRN . |
08/21/2023
| Implemented |
| 6400.166(b) | On 7/19/23, the pill pack for Individual #1's prescribed pro re nata medication, Ibuprofen Tab. 600 MG, was observed with a dispensed tablet blister and the date of 7/2/23 written beside it. However, initials of the person conducting and recording administration of the above medication on 7/2/23 were not found on Individual #1's July 2023 Medication Administration Record. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The information in subsection a12 and 13 shall be recorded in the MAR at the time medication is adminstered. |
08/21/2023
| Implemented |
| 6400.182(b) | Individual #1's admission date is 9/9/22. Their record did not include documentation of an individual plan having ever been developed since admission, as an initial assessment for Individual #1 has not been completed. | The initial individual plan shall be developed based on the individual assessment within 90 days of the individual's date of admission to the home. | THe individual plan shall be developed based on assessment within 90 days of submission |
08/21/2023
| Implemented |