| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.43(c) | Staff #1, who serves as the Agency's chief executive officer, does not meet the minimum educational level required by this regulation. Staff #1 has a high school diploma but does not have a bachelor's degree or master's degree. | A chief executive officer shall have one of the following groups of qualifications: (1) A master's degree or above from an accredited college or university and 2 years work experience in administration or the human services field. (2) A bachelor's degree from an accredited college or university and 4 years work experience in administration or the human services field. | This violation occurred based on BroMack's misunderstanding of our initial licensing. When were initially licensed we provided credentials for all of our administrative positions (Program Specialist, Executive Director and CEO) and were approved based on those collective credentials. The administrative structure of BroMack, LLC is such that the Executive Director performs the duties of the CEO as outlined in the 6400 regulations. This Executive Director possess the credentials necessary to perform these duties. |
04/04/2022
| Implemented |
| 6400.73(a) | The staircase leading to the attic had 11 steps and there was no handrail.
*This violation was corrected within 24 hours of the inspection. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | BroMack Living, LLC corrected this violation within 24 hours of the inspection and sent photographic evidence as such to the inspector. |
03/12/2022
| Implemented |
| 6400.207(4)(I) | The medication Olanzapine. 5mg. tablets, was prescribed for Individual #1 to be administered to the individual on a pro re nata basis for "agitation/psychosis." The Medication Administration Record (MAR) did not contain a protocol or instructions when to administer the medication, nor did it contain a specific description of symptoms or behavior that would indicate to staff that the individual was experiencing agitation or psychosis, and therefore required the medication. | A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition. | This violation occurred due to an oversight by the administrative team. This individual came to us June 15, 2020 with this PRN and without a protocol. This should have been noticed then. This individual never needed to use this PRN. It was discontinued in August of 2020 and was removed from the MAR, however the medication stayed in the medication cabinet. This medication should have been returned to the pharmacy upon discontinuation in August 2020 as this is protocol when discontinuing medications. After the Inspector called our attention to this violation, the medication was immediately returned to the pharmacy to be discarded. We have reviewed the Mental Retardation Bulletin 00-02-09 with the administrative team and all Residential Supervisors. This bulletin outlines the need for written protocols for all psychiatric PRNs. We currently do not serve any individuals that have a psychiatric PRN, but have put procedures in place to avoid such a violation in the future. |
04/07/2022
| Implemented |