| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | At time of monitoring the "Resident Transaction Account Logs" for Individual #1 indicated a purchase of "lunch" was made in the amount of $32.74 on 8/20/22. The assessment dated 6/30/22 for Individual #1 indicates that "does not make purchase without assistance" and "does not make or count change correctly." All purchases are made in conjunction with provider staff members who hold and use the debit card belonging to Individual #1 on their behalf. Individual #1's repayee and power of attorney disputed the amount and requested itemized documentation and receipt of the purchase. Documentation was not provided. Individual funds are to be used solely for the benefit of the Individual and may only be used for an admission or similar expense relating to an activity the Individual wishes to attend if the Individual may freely choose to use their personal funds to pay for the staff person. | Individual funds and property shall be used for the individual's benefit. | 6400.22C
Individual¿s funds and property shall be used for the individual¿s benefit. It is important that all transaction receipts be kept and tracked to ensure that the individual funds and properties are being used for the benefit of the individual. This is to ensure that the individual(s) not being financially exploited
Resident Transaction Account Logs for this individual indicated a purchase of ¿lunch¿ was made in the amount of $32.74 on 08/20/22. The documents were not sent upon request.
Even though Individual #1¿s assessment indicates that ¿he does not make purchase without assistance¿ and ¿does not make or count change correctly.¿ Individual #1¿s family member with the `Power of Attorney¿ insisted that Individual #1 keeps the debit card and swipes it to make purchases.
ICLP has a Memorandum sent in each home for any purchases over $15 must seek supervisor or Program Specialists approval for all individuals. Every transaction receipt will be kept and login to the RTA each time. |
01/31/2023
| Implemented |
| 6400.22(d)(1) | The provider assessment dated 6/30/22 for Individual #1 indicates that "does not make purchase without assistance" and "does not make or count change correctly." All purchases are made in conjunction with provider staff members who hold and use the debit card for Individual #1 on Individual #1's behalf. At time of monitoring $9.00 in cash was located in the financial documents and belongings of Individual #1. There was no documentation of the funds on the "Resident Transaction Account Log" found in the home covering the period of 8/1/22 to 11/11/22. The cash was reported by Individual #1's parent to be reimbursement for overspending on a lunch purchased with Individual #1's debit card on 8/20/22 in the amount of $32.74 for "lunch." The reimbursement deposited with the home is required to be entered onto an up-to-date financial record. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | 6400.22(d)(1)
Supports individuals with financial and property management; ensures accountability of individual¿s resources.
At time of monitoring $9.00 in cash was located in the financial document s and belongings of individual #1. There was no documentation of the funds on the ¿Resident¿s Transaction Account Log¿ found in the home covering the period of 8/1/22 to 11/11/22.
The cash was reimbursement for overspending on a lunch purchased with individual #1¿s debit card on 8/20/22 in the amount of $32.74 for ¿lunch¿. The reimbursement deposited with the home was not entered onto an up-to-date financial record. The Program Specialist explained he could not keep and up-to-date financial record at the time due to the refusal of individual #1¿s mother to share individual #1¿s monthly financial statement with the agency. (Attachment #6) please see numerous communications to that effect.
The reimbursement deposited with the home is required to be entered onto an up-to-date financial record. We have kept a record of every spending done by the individual with receipts while in our care. These receipts have been entered in individual #1¿s Transaction Account Log. |
01/31/2023
| Implemented |
| 6400.22(e)(3) | The provider assessment dated 6/30/22 for Individual #1 indicates that "does not make purchase without assistance" and "does not make or count change correctly." All purchases are made in conjunction with provider staff members who hold and use Individual #1's debit card on Individual #1's behalf. The "Resident Transaction Account Log" covering the time period of 8/1/22 to 8/20/22 documents a purchase of $32.74 for "Lunch/Dining." Receipts and monthly financial ledgers were requested on 11/29/22 and 12/5/22 but were not received. There is no corresponding receipt or expense record to verify the purchase as required. The "Resident Transaction Account Log" covering the period of 8/26/22 to 11/11/22 notes four purchases exceeding $15 that lack actual receipt or expense record to verify the purchase as required. On 8/26/22 a purchase in the amount of $18.70 "Lunch/Jersey," 9/2/22 a purchase in the amount of $17.26 "Lunch Red Robin," 9/7/22 a purchase in the amount of $21.55 "Lunch/Chili Grill bar," 10/14/22 a purchase in the amount of $24.34 "Lunch/Starlite Diner." Each single purchase exceeding $15 made on behalf of the individual, carried out by or in conjunction with a staff person requires documentation by actual receipt or expense record to satisfy regulation. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | 6400.22e(3)
Documentation by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual ensures accountability of individual¿s resources.
The provider assessment dated 6/30/22 for individual #1 indicates that ¿does not make purchase without assistance¿ and ¿does not make or count change correctly.¿ All purchases are made in conjunction with provider staff members who hold and use individual #1¿s debit card on individual #1¿s behalf. The ¿Resident Transaction Account Log¿ covering the time period of 8/1/22 to 8/20/22 documents a purchase of $32.74 for ¿Lunch/Dinning¿. Receipts and monthly financial ledgers were requested on 11/29/22 and 12/5/22 but were not received. There is no corresponding receipt or expense record to verify the purchase as required.
The ¿Resident Transaction Account Log¿ covering the time period of 8/26/22 to 11/11/22 notes four purchases exceeding $15 that lack actual receipt or expense record to verify. Staff collected receipts of every purchase and kept in his personal ledger, unfortunately receipts of purchases scanned were not attached on the email sent to Licensing staff.
The financial record showed that receipts were kept for the individual #1. We have scanned individual receipts kept with us while in our care to Licensing staff for verification. |
01/31/2023
| Implemented |
| 6400.64(a) | The electric toothbrush belonging to Individual #1 was found lying behind the faucet of the bathroom sink with the head, or bristles, of the toothbrush touching the surface of the faucet. The toothbrush was uncovered. The light-colored fabric seats of the dining room chairs were visibly soiled. The dining room carpet had several stains and a heavily soiled area leading from the kitchen into the dining area. Two half gallon containers of Minute Maid juice were found in the lower cabinet of the shared wall between the kitchen and dining room. Directions on the Minute Maid containers included "Keep Refrigerated." The containers were room temperature when touched and expanding. | Clean and sanitary conditions shall be maintained in the home. | 6400.64(a)
Clean and sanitary conditions safeguard the health and wellness of both individuals and staff. It minimizes the risk of illness, infection or injury and provide for dignifies living environment.
The electric toothbrush belonging to individual #1 was found lying behind the faucet of the bathroom sink with the head, or bristles, of the toothbrush touching the surface of the faucet. The toothbrush was uncovered. The light-colored fabric seats of the dining room chairs were visibly soiled. The dining room carpet has several stains and a heavily soiled area leading from the kitchen into the dining area. Two half gallon containers of Minute Maid juice were found in the lower cabinet of the shared wall between the kitchen and dining room. Directions on the Minute Maid containers included ¿Keep Refrigerated.¿ The containers were room temperature when touched and expanding.
Individual #1 while packing for weekend forgot to take his toothbrush with him. Staff didn¿t check his room after he left and didn¿t know whether his toothbrush was in his bathroom.
On the fabric seat, the staff on shift explained to management that she was going to clean and dust the seat during her shift. However, staff was helping another individual who resides with individual #1 when licensing staff showed up.
The two-half gallon Minute Maid was left outside in the lower cabinet for easy access since individual #1¿s mother requested that he be redirected to take juice rather than taking food in the refrigerator as he is gaining weight lately. This was agreed at a team meeting held at the house on
The Program Specialist and the house supervisors have developed a shift responsibility sheet for staff. Supervisors will check each shift to ensure clean and sanitary conditions are maintained in the homes. |
01/31/2023
| Implemented |
| 6400.144 | Individual #1 has a pacemaker that requires 91 day checks as prescribed by the Cardiologist. The 9/5/22 pacemaker check was not completed as scheduled on 9/5/22 but was completed on 9/11/22. This would extend beyond the 91 days and five day grace period. There was no documentation submitted to support that the December pacemaker check had been completed as scheduled. A cardiologist appointment form was submitted for the appointment on 12/5/22. The form simply states "Pacer." There were no reports submitted to indicate that the pacemaker check had been completed as scheduled on 12/12/22. A text message from Medtronic was received by Individual #1's family member indicating that the pacemaker check was not completed as scheduled on 12/12/22. Pacemaker checks completed on 6/6/22 and 9/11/22 included detailed reports of the functioning of the pacemaker. There were no such reports submitted for the scheduled December pacemaker check.
Individual #1 has a planned dietary recommendation in place. It is evidenced by weight gain; admitting weight for Individual #1 on 6/1/22 was 210lbs while weight documented by Cardiologist on 12/5/22 was 235lbs, bouts of documented intestinal distress resulting in medical treatment and lack of adequate staff training that the dietary plan has not been followed as planned. Health services that are planned or prescribed for the individual shall be arranged for or provided to ensure compliance with regulation and health and safety of individuals. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| 6400.144
When individuals have conditions that require referral to specialty medical personnel, providers must assure that services occurred at the periodicity recommended and that recommendation is followed. It protects individuals¿ health and safety by ensuring the provision of appropriate medical and psychological services.
Individual #1 has a pacemaker that requires 91 day checks as prescribed by the Cardiologist. The 9/5/22 pacemaker check was not completed as scheduled on 9/5/22 but was completed on 9/11/22. This would extend beyond the 91 days and five-day grace period. There was no documentation submitted to support that the December pacemaker check had been completed as scheduled. A cardiologist appointment form was submitted for the appointment on 12/5/22. The form simply states ¿Pacer.¿ There were no reports submitted to indicate that the pacemaker check had been completed as scheduled on 12/5/22. A text message from Medtronic was received by individual #1¿s family member indicating that the pacemaker check had not been completed as scheduled on 12/11/22. Pacemaker checks completed on 6/6/22 and 9/11/22 included detailed reports of the functioning of the pacemaker. There were no such reports submitted for the scheduled December pacemaker check.
Individual #1 has a planned dietary recommendation in place. It is evidenced by weight gain; admitting weight for individual #1 on 6/1/22 was 210lbs while weight documented by Cardiologist on 12 12/5/22 was 235lbs, bouts of documented intestinal distress resulting in medical treatment and lack of adequate staff training that dietary plan has not been followed as planned. Health services that are planned or prescribed for the individual shall be arranged for or provided to ensure compliance with regulation for health and safety of individuals.
On 9/5/22 the supervisor said he scanned the pacemaker as he has done before. However, the nurse was notified on 9/11/22 by individual #1¿s mother that the doctor said that the test was not completed. The nurse immediately went to the house and have it completed.
The 12/5/22 report showed that the pacemaker test was completed (Attachment #)
Our records did not show that individual #1 has an appointment or pacemaker test on 12/11/22. Our last summary visit to the cardiologist states 12/5/22 and not 12/11/22 (attachment #). However, based on the instructions given by individual #1¿s mother the doctor is not allowed to communicate with us on whether the reading goes through or not. Individual #1¿s mother has the power of attorney and therefore did not include ICLP in the release form for individual #1¿s doctors to contact ICLP.
Individual #1 has a planned dietary recommendation in place. ICLP has followed the planned menu provided by the dietician. Individual #1 was not put on a special diet that needs training. On individual #1¿s physical form the doctor recommended that ICLP follows the dieticians plan (Attachment #). The plan we have from the dietician is the menu given to ICLP which has been followed.
Regarding pacemaker checks: - the supervisor was counseled on the importance of following physician's written orders as well as making sure verbal orders are matching of the written orders. The nurse will always do a follow up with staff Keep prescribed dates of medical plan unless otherwise directed by the doctor to change the plan.
The Nurse shall ensure that staff trainings are completed on all medical protocols or written orders by doctors. Please see attached recent protocol trainings completed for staff agency wide to keep up and maintain this regulation. (Attachment #)
According to the doctor¿s summary 12/5/22 was the only printed date in his notes sent to the home. There was no mention of 12/12/22 reading to be completed. When the doctor was asked, he informed ICLP it was only for billing purposes. Please see 12/5/22 pacemaker reading from doctor¿s office. |
01/31/2023
| Implemented |
| 6400.211(a) | At the time of monitoring Staff #1(hire date 6/5/22) was requested to provide emergency information for Individual #1. Staff #1 was not able to easily access the information in the home. A copy of Individual #1's most recent Individual Support Plan was in the home and contained items as required in 6400.211b1-4 but was not easily accessible as Staff #1 had to contact another staff member by phone in order to be instructed where to find the information. A copy of Individual #1's most recent annual physical examination was not in the home as required in 6400.211 b 4. Emergency information must be easily accessible in the home to satisfy regulation. | Emergency information for an individual shall be easily accessible at the home.
| 6400.211(a)
Emergency information for an individual shall be easily accessible at home. This ensures that critical health information is available in the event of a medical emergency.
Staff #1 (hire date 6/5/22) was requested to provide emergency information for individual #1. Staff #1 was not able to easily access the information in the home. A copy of individual #1¿s most recent Individual Support Plan was in the home and contained items as required in 6400.211 b1-4 but was not easily accessible as Staff #1 had to contact another staff member by phone to be instructed where to find the information. A copy of individual #1¿s most recent annual physical examination was not in the home as required in 6400.211b4. Emergency information must be easily accessible in the home to satisfy regulation.
Staff #1 was not able to easily access the information in the home. Staff #1 had to contact another staff member by phone to be instructed where to find the information. Staff #1 said the program book was removed from the usual location and placed in another location and she was not aware.
ICLP management has agreed that Program Specialists should review in staff meetings where Emergency Information can be found for Individuals.
To make emergency information accessible to staff, all individuals emergency information can be found in the individuals Grab-and-Go bag in the home when they are at home or in the community. Also to have one consistent location. |
01/31/0202
| Implemented |
| 6400.214(a) | At the time of monitoring Staff #1 was requested to provide documents pertaining to Individual #1. Staff #1 was not able to find a current dated photo, physical examination, and assessment for Individual #1. Requested documents for Individual #1 were not available in the home or by electronic means as required. | Record information required in § 6400.213(1) (relating to content of records) shall be kept at the home. | 6400.214(a)
Record information required relating content of records shall be kept at the home. Table of content in individuals program book helps protect individual privacy and helps staff locates required information easily.
At the time of monitoring Staff #1 was requested to provide documents pertaining to individual #1. Staff #1 was not able to find a current dated photo, physical examination, and assessment for individual #1. Requested documents for individual #1 were not available in the home or by electronic means as required.
. Staff #1 said the records were removed from the usual location and placed in another location and she was not aware.
Effective immediately Management have agreed that review of the program book will also be completed at monthly staff meetings for all the homes by the Program Specialists. This will help staff to easily locate any information requested by external agencies, County representatives and the State or investigators. |
01/31/2023
| Implemented |
| 6400.18(b)(2) | On 8/16/22 the Provider discovered an error with the Symbicort 80-4.5mcg inhaler belonging to Individual #1. An exact time frame was not provided but the Provider noted in an email to supports coordination that "the medication ran out before they got the refill." There was no incident report filed in the Enterprise Incident Management (EIM) despite the Provider statement of "will enter the missed medication into HCSIS today. Because I discover it today." There were no corresponding medication errors filed within the appropriate timeframe or thereafter. Medication errors are to be entered into EIM within 72 hours of discovery by a staff person. | 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 72 hours of discovery by a staff person:
A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner. | 6400.18(b)(2)
Recognizing and reporting incidents is the first step to ensure a provider organization has a robust incident management and risk mitigation process that reduces the likelihood of recurrence of injury or harm to individuals receiving supports
On 8/16/22 the provider discovered an error with the Symbicort 80-4.5 mcg inhaler belonging to individual #1. An exact timeframe was not provided but the provider noted in an email to support coordinator that ¿the medication ran out before they got the refill.¿ There was no incident report filed in the Enterprise Incident Management (EIM) despite the provider statement of ¿will enter the missed medication into HCSIS today. Because I discover it today¿. There was no corresponding medication errors filed within the appropriate timeframe or thereafter. Medication errors are to be entered into EIM within 72 hours of discovery by a staff person.
This plan of extensive correction is intended to correct the failure to enter an alleged incident and suspected incident of medication error on 8/16/22 which is the date of discovery within 72 hours into the incident EIM system.
However, the incident Manager has entered the incident in the EIM system to maintain regulation. The evidence of completed training of the Incident Manager, documentation of the incident into the EIM system and the plan for continuous improvement and training in these areas is located throughout this plan of correction and in all the attachments. |
02/01/2023
| Implemented |
| 6400.52(b)(5) | Staff #5 has a documented hire date of 10/6/22. There was no documentation to illustrate that training on all knowledge and skills necessary for the health, safety and welfare of the specific individuals served was completed within 30 days of hire. Documentation of training on the Behavioral Support Plan for Individual #1 was not submitted to verify training was completed as required. There was no documentation to illustrate that Staff #1-#5 had training on Individual #1's prescribed and recommended diet. | The following shall complete 12 hours of training each year: Paid and unpaid interns who work alone with individuals. | 6400.52(b)(5) The importance of this regulation ensures that staff who work directly with individuals receive the training necessary for safety to support them and staff that is working with individuals are knowledgeable about the needs of the person; the practices to assure the person¿s health, safety and welfare of the individual (s) served is met.
Staff #5 has a documented hire date of 10/6/22. There was no documentation to illustrate that training on all knowledge and skills necessary for health, safety and welfare of the specific individuals served was completed within 30 days of hire. Documentation of training on the Behavioral Support Plan for Individual #1 was not submitted to verify training was completed as required. There was no documentation to illustrate that Staff #1-#5 had training on Individual #1¿s prescribed and recommended diet.
Staff #5 hire date of 10/6/22 has training completed on individual #1¿s Behavior plan. ICLP unfortunately didn¿t send the Behavior Support Training of staff #5 to the licensing staff.
Staff #1 is missing his BSP training from the training requirement sent to the Licensing staff. Upon our review the training was completed but was missed while the rest of the training documents were scanned to the Licensing staff. (Attachment #).
There is no specific diet Training for Staff #1-#5 on individual #1¿s recommended diet. Individual #1¿s doctor recommended that ICLP should follow the dietician¿s plan. Please see individual 1¿s physical. |
01/31/2023
| Implemented |
| 6400.165(c) | On 8/16/22 the Provider discovered an error with the Symbicort 80-4.5mcg inhaler belonging to Individual #1. An exact time frame was not provided. The Provider noted that "the medication ran out before they got the refill." There were no corresponding medication errors filed. Timeframe for the lack of medication could not be determined. Provider statement indicates that the medication was not administered as prescribed. | A prescription medication shall be administered as prescribed. | 6400.165C
A prescription medication shall be administered as prescribed. It prevents medication errors that could result in injury
On 8/16/22 the Provider discovered an error with Symbicort 80-4.5mcg inhaler belonging to individual #1. An exact time frame was not provided. There were no corresponding medication errors filed. Timeframe for the lack of medication could not be determined. Provider statement indicates that the medication was not administered as prescribed.
The ICLP noted that ¿the medication ran out before it got refilled.¿ Several calls were made to the prescribing doctor for refills prior to medication running out. Individual #1¿s Mother also tried reaching out to doctor for refill and it was not available.
ICLP have always followed a standard practice of filling out prescription orders from doctors a week in advance. The medication was refilled a day later 8/16/22 and was immediately taken to individual #1¿s home while on weekend with mother by Program Specialist.
Program Specialist has entered the medication error on the incident EIM system on 2/2/2023. Incident case number |
02/02/2023
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medication to treat symptoms of a psychiatric illness. The medications were reviewed on 7/11/22. Documentation of the review did not include the reason for prescribing the medication, the need to continue the medication and the necessary dosage. There was no documentation to indicate to that additional reviews had been completed within the required 3-month time frame. Review following the review conducted on 7/11/22 should have occurred by 10/16/22. The was no documentation to verify that the 10/22 review was conducted as required. | 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. | 6400.165(g)
If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. It ensures that medication prescribed for treatment of a psychiatric illness are used exclusively for the treatment of the illness.
Individual #1 is prescribed medication to treat symptoms of a psychiatric illness. The medications were reviewed on 7/11/22. Documentation of the review did not include the reason for prescribing the medication, the need to continue the medication and the necessary dosage. Reviews following the review conducted on 7/11/22 were 10/24/22 and 12/19/22.There are case notes that shows the appointments occurred, however the documentations were not done on the right format form for Psyc.
All the 3 case notes did not indicate the need to continue the medication and the necessary dosage. There is additional documentation to show that the 3-month review was completed on 7/11/22, 10/24/22 and 12/19/22
Individual #1 appointment was not completed on 10/16/22 due to Psychiatrists availability. Individual #1 was given a return date of 10/24/22. Upon Management review of the hospital summary. Though the medical case notes on 10/24/22 does note states whether the medication was reviewed, however, the attached hospital summary notes does confirm that a review of the medication was completed. |
01/31/2023
| Implemented |