| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Individual #1's abuse incident #9038143 , was discovered by the agency 6/04/2022 and not reported to the Department until 6/09/2022. Individual #1 did not receive medical attention regarding the abuse allegation, after the incident was discovered. The target staff was not suspended while the investigation was still pending and one of the target's was working in the home during the inspection. Individual #1's supervision needs were not being met during the inspection. The individual's individual support plan, last updated 5/06/2022, states he is never to be left alone with 2:1 staff during awake hours and one staff being within line of sight and the other staff being within hearing distance. During the inspection Individual #1 was alone upstairs in his bedroom, while Direct Support Worker #1 and Direct Support Worker #2 remained on the couch in the living room on the first floor of the home. Incident #9038143 was determined to have been founded by multiple interviews conducted and the individual having a bruise where the individual reports the abuse occured. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | The Program Specialist will train Direct Care Support Professionals on the different forms of abuse and the individual's rights. Staff will be trained on how to ensure we respect and uphold the individual's rights, along with not engaging in any restrictive support that is not called for in the individual's plan. The Human Rights Team will be deciding whether a restrictive procedure plan will be deemed necessary regarding providing support to this individual. The Program Director will be training Direct Care Support Professionals in Crisis Prevention Intervention (CPI), giving them tools to assist in deescalating situations once they are heightened or prevent them from escalating and/or physically assistive techniques to use to keep staff and the individual safe in the event of a crisis. [ a copy of the Program Specialist's CPI Training Certification will be sent to the Director] |
07/26/2022
| Implemented |
| 6400.141(a) | Individual #1, date of admission 5/31/2022, does not have documentation of a physical examination having been completed within 12 months prior to admission. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | A copy of the physical examination was performed by a MD on 2-9-2022 and will be submitted to the Department. |
08/17/2022
| Implemented |
| 6400.18(g) | Individual #1 reported to staff on 6/04/2022, that a staff member kicked and punched him and the agency reported the incident #9038143 in the Department's information management system 6/09/2022 and began the investigation at that time. | The home shall initiate an investigation of an incident, alleged incident or suspected incident within 24 hours of discovery by a staff person. | Provider¿s Plan of Correction
LRS policy was updated to include a section on the response upon discovery/recognition of an incident. If a reportable incident occurs, and is witnessed by LRS staff, that person (initial reporter shall: (1) notify the LRS Point Person (s) Chief Operating Officer (COO) ¿ Primary Point Person and Program Specialist/Director -Secondary Point Person, respectively; (2) document the observations about the incident in narrative format in the Incident Reporting Log; and (3) comply with the applicable laws and regulations for incidents of alleged abuse, neglect, and exploitation |
07/25/2022
| Implemented |
| 6400.31(a) | During the inspection conducted 6/10/2022, Individual #1 had all sharp items in the home locked up, but did not have a restrictive procedure plan implemented, infringing on his right to make choices and accept risks. | An individual may not be deprived of rights as provided under § 6400.32 (relating to rights of the individual.) | The Program Specialist will train Direct Care Support Professionals on the individual's rights. Staff will be trained on how to ensure we respect and uphold the individual's rights, along with not engaging in any restrictive support that is not called for in the individual's plan. |
07/24/2022
| Implemented |
| 6400.52(c)(6) | There is no record of any of the staff working in Individual #1's home having been trained on implementation of the individual's plan. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | The Program Specialist will train Direct Care Support Professionals on the individual's rights. Staff will be trained on how to ensure we respect and uphold the individual's rights, along with not engaging in any restrictive support that is not called for in the individual's plan. [ a copy of the ISP training signoff sheet is sent to the Director. |
07/24/2022
| Implemented |
| 6400.162(a) | Direct Service Worker #1 and Direct Service Worker #2 administered medications for Individual #1 throughout June 2022 and did not complete medication administration training. | A home whose staff persons or others are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication. | LRS provides medication administration training for all new staff. [ a copy of the sign off sheets for the training conducted has been sent to the Director. |
07/30/2022
| Implemented |
| 6400.163(a) | During the inspection conducted 6/10/2002, Individual #1's medications were removed from the original package, put in zip lock bags with day and time of administration, and did not include a label issued by a pharmacy. there was also an unidentified pill out of the original container, in a zip clock bag. Agency was unable to provide documentation for this medication. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | To correct the problem, LRS has a contract with PDC Pharmacy to provide bubble pack medications. |
08/24/2022
| Implemented |
| 6400.166(b) | Individual #1's Ammonium Lactate 12% Cream, Clotrimazole-Betamethasone Cream, Divalproex Sod ER 250mg tablet, Januvia 100mg tablet, Levemir Flextouch 100unit/ml insulin pen, Levothyroxine 175mcg tablet, Lisinopril 2.5mg tablet, Lithium Carbonate ER 300m tablet, Lovaza 1gm capsule, Metformin HCL 1,000mg tablet, Novolog 100unit/ml flexpen, Pantoprazole Sod DR 20mg tablet, Propranolol 40mg tablet, Refresh Classic Eye Drops, Simethicone 80mg chewable tablet, Vitamin D3 5,000 unit softgel, and Ziprasidone HCL 60mg capsule were not administered 6/02/2022 through 6/06/2022 at 8:00AM; Clonazapam 1mg tablet were not administered on 6/03/2022 through 6/06/2022 at 8:00AM; Novolog 100unit/ml flexpen were not administered on 6/02/2022 through 6/04/2022, 6/06/2022, and 6/08/2022 at 9:00AM; Novolog 100unit/ml Flexpen were not administered on 6/02/2022 through 6/06/2022 and 6/08/2022 at 12:00PM; Simethicone 80mg chewable tablet were not administered on 6/02/2022, 6/04/2022 through 6/06/2022, and 6/08/2022 at 12:00PM; Novolog 100 unit/ml Flexpen were not administered on 6/02/2022 and 6/04/2022 through 6/08/2022 at 1:00PM; Propanolol 40mg tablet and Refresh Classic Eye Drops were not administered on 6/04/2022, 6/06/2022, and 6/08/2022 at 5:00PM; Clonazepam 1mg tablet, Metformin HCL 1,000mg tablet, Novolog 100 unit/ml Flexpen, Simeythicone 80mg chewable tablet, and Ziprasidone HCL 60mg capsule were not administered on 6/04/2022, 6/06/2022, and 6/08/2022 at 5:30PM. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | On 6/26/2022, the staff member and Program Supervisor was notified about the date and time of medication administration and the name and initials of the staff administering the medication was not in compliance with our policies and procedures. |
06/26/2022
| Implemented |
| 6400.166(d) | Individual #1 has a doctor's order to check his blood glucose levels 4 times a day at 7:30AM, 11:30AM, 5:30PM, and 9:00PM. Individual #1's June 2022 medication administration record is missing documentation for 6/02/2022 blood glucose checks. Individual #1's record documents only one blood glucose check on the following dates: 6/04/2022, 6/06/2022, and 6/08/2022. Individual #1's record documents only two blood glucose checks on the following dates: 6/07/2022 and 6/09/2022. Individual #1's June 2022 medication administration record did not include the dose of administration for the Novolog 100 unit/ml Flexpen, with instructions to use a sliding scale for meal coverage (subcutaneously) after checking blood sugar. | The directions of the prescriber shall be followed. | Effective July 1, 2022, a Blood Glucose Log was developed to document glucose readings as prescribed by the doctor. Staff will still be required to include the readings in the medication records. [ a copy of the log has been sent to the Director] |
08/01/2022
| Implemented |