| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.43(b)(1) | There were no written policy and procedures provided during the inspection. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | Ensure that the policies and procedures are in a location obtainable to all staff |
05/09/2022
| Implemented |
| 6400.106 | There was no record or written documentation kept of an annual furnace inspection or cleaning. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| Program Director to provide a copy of the invoice with the information about the inspections of the furnace |
05/09/2022
| Implemented |
| 6400.113(a) | There was no record found that fire safety training was conducted for individual #1. | 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. | Individual #1 will be trained by the house manager and watch a fire safety video on youtube and documentation will be added to individual #1 file |
05/09/2022
| Implemented |
| 6400.141(c)(7) | There was no record that individual#1 had a gynecological exam, as that section of the physical exam dated 7/16/21 was left blank. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Individual #1 was scheduled for an appointment on 7/25/22 |
05/09/2022
| Implemented |
| 6400.142(a) | There was no record of a semi-annual dental exam for individual#1. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Individual #1 was scheduled for an appointment on 5/17/22 |
05/09/2022
| Implemented |
| 6400.144 | There was no record of a gynecological or dental exam scheduled or arranged for individual#1. | 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 GYN appointment is scheduled for 7/25/22 and the dental appointment scheduled for 5/17/22 |
05/09/2022
| Implemented |
| 6400.151(a) | Staff member #2 did not have a physical exam completed prior to employment. Date of hire was 2/10/22, the physical exam was completed 3/11/22. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Staff member #2 to provide physical exam information from previous place of employment that will be within the 1 year hire date |
05/09/2022
| Implemented |
| 6400.181(d) | The assessment was not signed and dated by the program specialist. | The program specialist shall sign and date the assessment. | The program director will QA all assessments to review for accurate information including signatures |
05/09/2022
| Implemented |
| 6400.181(e)(12) | The assessment did not include recommendations for specific areas of training, programming and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The program specialist shall look for a program to sign the client up for that includes educational options |
05/09/2022
| Implemented |
| 6400.184(c) | The individual plan team members did not sign and date the signature sheet. Although this meeting was conducted virtually, there was no validating documentation that this meeting was held and what was discussed by way of email correspondence. | A plan team member who attends a meeting under subsection (b) shall sign and date the signature sheet. | The program director to review all paperwork for attendance signature compliance |
05/09/2022
| Implemented |
| 6400.217 | There was no written consent for release of information found in the record for individual#1. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| Review forms with individual #1 to obtain signatures |
05/09/2022
| Implemented |
| 6400.24 | Staff member #1's criminal check was not completed until 4/18/22, date of hire was 9/21/21.
Staff member #2's criminal (4/18/22) and fbi (3/10/22) checks were completed after date of hire 2/10/22.
Staff member #3's fbi check was not completed and there was no record of residency prior to employment.
There was no record of residency found for the new hires prior to employment. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | Will ensure that no start date happens prior to all of the requirements being met |
05/09/2022
| Implemented |
| 6400.31(b) | There was no signed copy of the individual rights found in the record for individual#1. it could not be determined if the individual was educated about the right to make choices and informed of the individual's rights. | The home shall educate, assist and provide the accommodation necessary for the individual to make choices and understand the individual's rights. | Individual #1 signed release was emailed |
05/09/2022
| Implemented |
| 6400.163(a) | PRN-Diclofenac Sodium 1% gel (apply 1 gram every twelve hours as directed as needed for pain. this medication was not found in its original container at inspection. The original packaging could not be located. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | Medication Administration training was completed
on 4/22/22 |
05/09/2022
| Implemented |
| 6400.165(b) | Lisinopril hctz 20-12.5mg-take one tablet by mouth once daily. It could not be determined if the pill bottle or the blister pack was being used as both had medication remaining and there was no documentation or explanation found on the medication log as to what medication was being used daily.
1. Pill bottle-(4 left- dated 4/16/22)
2. Blister pack dated (2/2/22) dates not punched 23,24,29, 30 | A prescription order shall be kept current. | Medication Administration training was completed on 4/22/22 |
05/09/2022
| Implemented |
| 6400.165(b) | Buspirone 10mg tabs- take two tablets by mouth twice daily. It could not be determined if this medication was being administered properly as it appears both the pill bottle and blister pack may be used simultaneously. There is no documentation or explanation provided on the medication log. Staff was not able to provide an explanation for this during the inspection.
1. Pill bottle dated 4/16/22-8 tablets left enough for 2 days.
2. Blister pack dated (3/16/22)- 1 left on the 1st day of the month- it could not be determined if correct dosage was administered. Days-27,28,29,30-still in blister pack | A prescription order shall be kept current. | Medication Administration training was completed on 4/22/22 |
05/09/2022
| Implemented |
| 6400.166(a)(13) | The name and initials of the person administering the medication must be included on the medication log. Staff member #1 has initialed the medication log, but the staff member's name is not included on the medication log, making it difficult to determine who administered the medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | The house manager will monitor MAR logs daily. The House manager will check all medication received from the pharmacy before staff administers the medication |
05/09/2022
| Implemented |
| 6400.166(d) | PRN-Naproxen 500mg tabs pill bottle-(4/16/22)-take one tablet by mouth twice daily with food as needed for headaches. According to the medication log, this medication was administered and signed out daily from April 1- April 12, 2022 and discontinued being administered daily once it was discovered it was a PRN medication.
This medication was then re-written on medication log as a PRN medication. The directions of the prescriber shall be followed. | The directions of the prescriber shall be followed. | Medication Administration training was completed on 4/22/22 |
05/09/2022
| Implemented |
| 6400.166(d) | PRN-Tizanidine 4mg tab-blister pack dated 3/22/22-take one tablet by mouth every eight hours as needed for pain.
Handwritten on medication log-Tizanidine 4mg tab., take one tablet by mouth EVERY HOUR as needed. Also on the medication log 8am and 8pm dosages were administered April 1-April 19. The directions of the prescriber shall be followed. | The directions of the prescriber shall be followed. | Medication Administration training was completed on 4/22/22 |
05/09/2022
| Implemented |
| 6400.166(d) | Atorvastatin 40mg tab-(dated 4/16/22) take one tablet by mouth at bedtime. Mar shows this medication was initialed as given on day of inspection before bedtime. | The directions of the prescriber shall be followed. | Medication Administration training was completed on 4/22/22 |
05/09/2022
| Implemented |
| 6400.166(d) | PRN-Diclofenac Sodium 1% gel (apply 1 gram every twelve hours as directed as need for pain. The medication log lists this medication as being administered on the day of inspection at both 8am and 8pm. | The directions of the prescriber shall be followed. | Medication Administration training was completed on 4/22/22 |
05/09/2022
| Implemented |
| 6400.167(a)(4) | Atorvastatin 40mg tab-(dated 4/16/22) take one tablet by mouth at bedtime. Mar shows this medication was initialed as given on day of inspection before bedtime. | Medication errors include the following: Failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time. | Medication Administration training was completed on 4/22/22 |
05/09/2022
| Implemented |
| 6400.167(c) | Atorvastatin 40mg tab-(dated 4/16/22) take one tablet by mouth at bedtime. Mar shows this medication was initialed as given on day of inspection before bedtime. Medication errors shall be reported as a incident. | A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). | Medication Administration training was completed on 4/22/22 |
05/09/2022
| Implemented |
| 6400.181(f) | The program specialist did not provide the assessment to the individual plan team members 30 calendar days prior to the individual plan meeting. The assessment was sent 10/20/21, the individual plan meeting was held 10/28/21. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The program director will make sure going forward that the timelines are adhered to |
05/09/2022
| Implemented |
| 6400.213(1)(i) | The religious affiliation of individual#1 was listed as unknown in the record. Staff states the individual was not asked about religious affiliation.
There was no current dated photo found in the record for individual#1. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Face sheet emailed with Religious affiliation and current photo |
05/09/2022
| Implemented |