| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.81(k)(6) | On 4/28/21 at 10:30 AM, Individual #1's bedroom did not have a mirror. | In bedrooms, each individual shall have the following: A mirror. | On 4/28/21 auditors made Tucker Family Supports (TFS) aware that all consumer individuals shall have a mirror. The evening of 4/28/21 TFS staff retrieved a mirror for the consumer BK. |
04/28/2021
| Implemented |
| 6400.111(c) | On 4/28/2021 at 10:23 AM, the kitchen of the home did not have a fire extinguisher. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | On 4/28/2021 auditors made Tucker Family Supports (TFS) aware that the fire extinguisher that was located in the dining room was too far away from the kitchen. On the evening of 4/28/2021, TFS moved the fire extinguisher on the wall into the kitchen location. |
04/28/2021
| Implemented |
| 6400.112(c) | The written fire drill records completed January 2021, February 2021 and April 2021, do not include the amount of time it took for evacuation. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | On 4/29/2021, 5/5/2021, Tucker Family Supports staff and house supervisor were retrained on fire safety documentation and evacuation by a safety expert. Tucker Family Supports updated the evacuation form to monitor ongoing compliance with a regulatory requirement with the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. |
05/01/2021
| Implemented |
| 6400.112(d) | The fire drill held 3/18/2021 had an evacuation time of 3 minutes. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | Tucker Family Supports (TFS) staff has been retrained and educated on the evacuation time and limitations with a fire safety expert on 5/15/2021. A fire drill will be conducted and timed by local fire safety expert. |
05/15/2021
| Implemented |
| 6400.141(c)(3) | Individual #1's physical examination, completed 8/13/2020, did not include a tetanus immunization. The most recent tetanus immunization completed 2/24/2009. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Tucker Family Supports (TFS) updated the staff and consumer physical form to properly document immunizations as well as communicable diseases. BK is scheduled to receive a tetanus shot on 7/15/2021 at his primary care physician. |
07/15/2021
| Implemented |
| 6400.141(c)(4) | Individual #1's physical examination, completed 8/13/2020, did not include a vision and hearing screening. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Tucker Family Supports (TFS) added and updated the staff and consumer physical form to properly document vision and hearing screens. |
05/05/2021
| Implemented |
| 6400.141(c)(10) | Individual #1's physical examination, completed 8/13/2020, did not address communicable disease. | 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. | Tucker Family Supports (TFS) updated the staff and consumer physical form to properly document immunizations as well as communicable diseases and included specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. |
05/05/2021
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination, completed 8/13/2020, did not include information pertinent to diagnosis in case of emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The TFS physical examination forms have been updated to include pertinent medical information relative to diagnosis and treatment in case of an emergency. |
05/05/2021
| Implemented |
| 6400.141(c)(15) | Individual #1's physical examination, completed 8/13/2020 did not include special instructions for the Individual's diet. | The physical examination shall include:Special instructions for the individual's diet. | Tucker Family Supports physical examination form has been updated to include special instructions for the individual's diet. |
05/05/2021
| Implemented |
| 6400.181(e)(10) | Individual #1's assessment, completed 9/14/2020, did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | The client's assessment form has been updated to include a lifetime medical history. |
05/05/2021
| Implemented |
| 6400.181(e)(11) | Individual #1's assessment, completed 9/14/2020, did not include a psychological evaluation. | The assessment must include the following information: Psychological evaluations, if applicable. | The client's assessment has been updated to include his psychological evaluation. |
05/05/2021
| Implemented |
| 6400.181(e)(13)(i) | Individual #1's assessment, completed 9/14/2020, did not include the individual's progress over the last 365 calendar days and current level in the following areas: Health. | The assessment must include the following information: | The client's assessment has been updated to the the individual's progress over the last 365 calendar days and current level in the following areas: Health. |
05/06/2021
| Implemented |
| 6400.181(e)(13)(vi) | Individual #1's assessment, completed 9/14/2020, did not include the individual's progress over the last 365 calendar days and current level in the following areas: 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 client's assessment has been updated to the individual's progress over the last 365 calendar days and current level in the following areas: recreation. |
05/06/2021
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's assessment, completed 9/14/2020, did not include the individual's progress over the last 365 calendar days and current level in the following areas: 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 client's assessment has been updated to the individual's progress over the last 365 calendar days and current level in the following areas: financial independence. |
05/06/2021
| Implemented |
| 6400.181(e)(14) | Individual #1's assessment, completed 9/14/2020, did not include information the individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | The client's assessment has been updated to the individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. |
05/06/2021
| Implemented |
| 6400.166(a)(7) | Individual #1 is prescribed Melatonin 5mg, take 2 tablets by mouth at bedtime. The Medication Administration Record for April 2020 states that Individual #1 should be administered Melatonin 5mg, take 1 tablet by mouth at bedtime. Individual #1 is prescribed Famotidine 40mg, take 1 tablet by mouth at bedtime. The Medication Administration Record for April 2020 states that Individual #1 should be administered Famotidine 40mg, take 1 tablet by mouth 2 times per day. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | Tucker Family Supports (TFS) contacted the consumer's physician concerning dosage and label for documentation. The dosage and time was updated in the client MAR. A new MAR was created for the Melatonin with the correct dosage information. Staff was retrained in medication administration and documentation of matching the medication label to the MAR. |
05/07/2021
| Implemented |
| 6400.182(c) | Individual #1's individual support plan, last updated 4/15/2021, states that Individual #1 understands they would need to evacuate a building in the event of a fire. Page one of the assessment, completed 9/14/2020, states that Individual #1 independently knows how to evacuate in case of fire. Page 3 states that Individual #1 requires Verbal Assistance to evacuate within 2 ½ minutes in case of fire. Individual #1's individual support plan, last updated 4/15/2021 states that Individual #1 enjoys swimming but should be visually monitored while doing so. The assessment completed 9/14/2020, for Individual #1 states that Ability to Swim does not apply to the personal needs or care of the individual. Individual #1's individual support plan, last updated 4/15/2021 states that Individual #1 takes out loans without paying them back, will apply for credit with high interest and spend the money immediately, stealing credit card numbers, and selling items that they do not own. The assessment completed 9/14/2020, for Individual #1 states that understanding concepts and consequences of owning, borrowing, and lending does not apply to the personal needs or care of the individual. Individual #1's individual support plan, last updated 4/15/2021 states that staff assist Individual #1 with Medication Administration. The assessment completed 9/14/2020 states that Individual #1 initiates and performs self-medication without a word, gesture, or touch. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The individual's assessment was updated accordingly to reflect the current goals and progress from the consumer's ISP. |
05/05/2021
| Implemented |