| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(2) | Individual #1 ISP reports that he is not capable of managing finances and has no concept of money. Also reflects that staff and individual go to the bank to withdraw money and also the individual is given $50 on Saturdays for activities, massages and snacks. Individual also has a credit card for his use. The agency has a policy a record for each individual will be kept for each consumer that clearly indicates all financial transactions, including expenses, deposits and withdrawals. | (2) Disbursements made to or for the individual.
| The agency has now developed a record keeping system to; retain and store all ATM receipts for individuals, obtain and retain receipts from individuals funds spending, and record an ongoing record of all disbursements of individuals funds. |
04/09/2021
| Implemented |
| 6400.82(f) | The bathroom did not have soap at the sink. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | The agency representative placed the hand soap at the sink at the time of inspection for this home's bathroom that did not have the hand soap present. |
04/07/2021
| Implemented |
| 6400.112(c) | There were fire drills conducted on 1/12/2021; 2/10/21; & 3/10/21, all of which did not have an exit route listed on the fire drill. | 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. | The agency revised the Fire Drill form for clarity to ensure each area of information is contained within the document and filled out by the staff person conducting the drill, specifically the time will be noted on each drill form. |
04/09/2021
| Implemented |
| 6400.112(h) | There were fire drills conducted on 1/12/2021; 2/10/21; & 3/10/21, all of which did not have a designated meeting place outside the building to show where they all met. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | The agency revised the Fire Drill form for clarity to ensure each area of information is contained within the document and filled out by the staff person conducting the drill, specifically to note the designated meeting place was utilized during the drill process. |
04/09/2021
| Implemented |
| 6400.141(a) | Individual #1 had a physical exam dated 3/5/2019 which was prior to his admission date. However, there was not a follow up exam annually for the year 2020. The next physical exam provided was dated 3/29/2021. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The agency will ensure that each individual's annual physical examination is conducted in a timely fashion, within annual time frames and are in compliance with the regulations. |
04/09/2021
| Implemented |
| 6400.141(c)(6) | Individual #1 had TB test on 2/27/2019 and it is due every two years which brings him to February 2021. Individual #1 did not have his current TB test until 3/31/2021. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | The Residential Director and the Clinical Manager will conduct Monthly Audits to ensure appointments are made within an allowance to ensure regulatory timeframes are met, specifically that the individual's TB Mantoux testing is completed in a timely fashion. |
04/09/2021
| Implemented |
| 6400.142(d) | Individual #1 did have a dental exam on 2/17/2021, however the report did not reflect if a cleaning was completed or not. | The dental examination shall include teeth cleaning or checking gums and dentures. | The agency has revised the Dental examination forms for clarity and to ensure that the services and the documentation of services are provided according to regulatory requirements. |
04/09/2021
| Implemented |
| 6400.151(c)(3) | Staff #1 had a physical which reflects it is yet to be determined if he is free of communicable diseases due to having a positive Quantiferon test. The exam reflects that staff was referred to an infectious disease dr and no further info was provided. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | Staff #1 was directed to provide the documentation for clarification and provided the same to the agency. |
04/09/2021
| Implemented |
| 6400.34(a) | Individual #1 had received and signed his individual rights on 6/1/2020, however those rights were not up to date to reflect the current regulations. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | The agency now uses the updated form, the individual had since signed prior to inspection, for all individuals. |
04/09/2021
| Implemented |
| 6400.51(b)(1) | Staff #2 did not have orientation
in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Staff #2 the CEO completed the 6100 training prior to the first individual being admitted to the residential program. Prior to that the CEO had only provided administration services In Home and Community Care.
The CEO will continue to perform regulatory annual trainings as required. |
04/09/2021
| Implemented |
| 6400.52(c)(1) | Staff #2 did not have annual training
in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Staff #2 the CEO completed the 6100 training prior to the first individual being admitted to the residential program. Prior to that the CEO had only provided administration services In Home and Community Care.
The CEO will continue to perform regulatory annual trainings as required. |
04/09/2021
| Implemented |
| 6400.163(a) | Individual #1 was prescribed sunblock SPF 45 which was not located with medications or with pharmacy label. Sunblock was found in the individual bathroom with hygiene supplies. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | Individual #1 had a prescription labeled sunscreen was placed in the medication box and locked per regulations. The sunscreen from the bathroom was removed and discarded. |
04/08/2021
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medications to treat psychiatric illness and there are no medication reviews on these medications which reflect the reason for the medication or the need to continue to the medication | 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. | The agency revised the Psychotropic medication Review from for clarity and compliance with the regulatory requirements, specifically to address the reason for the medication, and the need to continue the medication. |
04/09/2021
| Implemented |