| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.113(a) | Fire safety training for Individual #2 last occurred on 9/14/20. Documentation for fire safety training did not include a current training date. Annual fires safety training is required. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | The Individual was retrained in Fire Safety Training. |
04/15/2022
| Implemented |
| 6400.141(a) | Physicals on file for Individual #2 were dated as occurring on 8/28/20 and 9/20/21. The time period between physicals extended beyond the annual requirement and grace period. Annual physicals are required. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The Individual's mother is also legal guardian for Ryan and refuses to allow the agency to arrange for or take him to medical appointments. The mother has requested we open a home in her hometown where she will be able to see him every few days but she will still maintain his medical care. In discussing this with the Inspectors we agreed that retaining copies of Emails in the record, wherein the agency is asking the mother for compliance with the regulatory timeframes for care, would be maintained moving forward. |
04/15/2022
| Implemented |
| 6400.165(f) | April 2022 Medication Administration Records for Individual #2 contained an entry for Clonazepam Tablet 1mg Take 1 tablet by mouth twice a day as needed for anxiety for up to 30 days. One pill had been administered at the home on 4/12/22. The administration was documented per regulation. Both Staff #1 and Staff #3 stated that there was no protocol in place to determine when to administer the mediation nor the proper procedure to follow. Both Staff #1 and Staff #3 were able to detail how to give the medication and qualifying factors to administer. Additionally, Individual #2 was able to state when they would need the medication and understood the ability to request. There was no evidence to support that the single dose of medication had been used as a chemical restraint. A written protocol to address the individual's social, emotional and environmental needs related to the symptoms of the psychiatric illness and the administration procedure for the Clonazepam is required. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | The SEEN Plan has been updated to include the instructions for administration of the PRN as directed by the Psychiatrist. The staff were educated in the PRN Protocol although it was not written in the SEEN Plan. |
05/02/2022
| Implemented |