| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | At the time of the inspection, I requested a financial log for this individual funds. It was reported that this individual is independent with financials and manages her own money. Upon review of the ISP and the assessment it appears that this individual is not as independent and needs assistance with her financial needs. There was no record to reflect any funds received or deposited within the home for this individual. | 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. | The individual is resistive to giving the card to the agency and said he can take care of his own money and doesn't want us involved. We were able to gain the dollar amount currently on the card and wrote it on the expense record. (Please see image sent via email) |
03/20/2023
| Implemented |
| 6400.62(c) | The first-floor full bathroom had a mermaid style hand soap dispenser. This dispenser did not have a label on it. It was unable to be determined if the liquid in this container was poisonous as it was not in the original labeled container. | Poisonous materials shall be stored in their original, labeled containers. | Staff threw the decorative soap dispenser away, all individuals are poison safe, and we will only use soap with a label bar or pump. |
03/20/2023
| Implemented |
| 6400.67(a) | At the time of the inspection the kitchen chair had pieces that were broken and hanging at the base of the chair. This was pointed out to staff during the physical inspection. The back door led to a semi screened in back porch. The screen door from this screened in porch was broken and did not have a handle which was operable. The screened in porch also had several windows of which the screens had fallen out and were on the ground below the window. | Floors, walls, ceilings and other surfaces shall be in good repair. | The chair was discarded and the landlord has the screens on order with installation to follow. |
04/30/2023
| Implemented |
| 6400.142(c) | The individual physical exam dated 5/23/2022 did not list the immunizations. | A written record of the dental examination, including the date of the examination, the dentist's name, procedures completed and follow-up treatment recommended, shall be kept. | Staff are taking the individual to medical provider with the agency paying the expense to fill out the documentation to include this information. |
04/30/2023
| Implemented |
| 6400.144 | The individual is prescribed a PRN of ibuprofen tablets 600mg to be given by mouth 4 times a day as needed with food. At the time of the inspection the PRN was not present in the home in the event that this individual would need the medication. | 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.
| The medication was purchased and is present in the home. |
03/20/2023
| Implemented |
| 6400.151(c)(2) | The physical provided for the date of 11/3/2020 had TB test and results which were read on 11/5/2020. The physical provided for the date of 10/30/22 did not have a tb test attached. Further request was sent and an updated TB test was not provided. The information reflects that the staff is not up to date with the TB requirements. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | The staff person submitted the TB Testing and results. (Please see the image sent via email) |
03/20/2023
| Implemented |
| 6400.181(e)(13)(vii) | The individual assessment rates her financial independence as a 5 (which means independent) in the following areas; recognizes money as a medium of exchange, has cash in possession without losing, can make small purchases, handles personal cash for the week, selects affordable items, produces exact amounts, accepts the importance of saving money. The progress over the last year states it stayed the same as previous records, but there is nothing to reflect what that previous record stated. Also this reports that she has exhibited some issues with spending as she does not budget well and the agency is working on that with her. This is confusing and it is unable to be determined due the wording on this assessment if this induvial is in fact independent with their money or if they need assistance in budgeting and if this has changed from one year to the next. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| The previous year assessment has been submitted and the agency has reached out to the SC to have an alignment of the documentation for oversight of funds appropriate to the individual and in keeping with the individuals rights. |
04/30/2023
| Implemented |
| 6400.163(a) | The PRN medication of Polyeth Glyc Powder 3350 did not have the pharmacy label present. The label appeared to have been torn off. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | The medication has been repurchased and the label is present. |
03/20/2023
| Implemented |
| 6400.166(a)(11) | The medication administration record for this individual did not state the purpose or diagnosis for the medication for any of her prescriptions. I brought this up at the time of inspection. Staff stated that they have to request the Dr write it out to be on the blister packs and to be written on the MAR print out | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Staff has written the reason for the medication on the MAR to come into compliance with the regulations. |
03/20/2023
| Implemented |
| 6400.182(a) | The current ISP states that individual has a difficulty understanding the concept of saving money and budgeting. The ISP also reflects that she will spend money given to her and is unable to save for items she may want. The ISP reflects that the individual needs assistance in managing her own money successfully. The current annual assessment rates this individual as independent in the financial indepence. The assessment and ISP do not match and it is unclear what the ability this individual has to manage her own funds. | The program specialist shall coordinate the development of the individual plan, including revisions with the individual and the individual plan team. | The staff have reached out to the Supports Coordinators requesting a meeting to correctly document the needs of the individual in the ISP. |
04/30/2023
| Implemented |
| 6400.213(1)(i) | Individual did not have a current dated photo at the time of inspection. In response, I requested this. At that time the agency provided a photo with the date of October 2, 2023. Due to that date being several months from now, it was not accurate to the time of the picture being taken. This does not allow me to verify that the photo provided was a current photo of the individual. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | The date has been corrected on the document as staff misdated it should have read 2022. |
03/20/2023
| Implemented |