| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | Individual #1 is currently receiving Snap Benefits. There are no logs documenting the debits and credits for the Snap Benefits Individual #1 receives. | 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. | A new financial record log was created just for individual #1 SNAP benefits, to keep track of funds and to keep them separate from their regular finances. |
03/06/2023
| Implemented |
| 6400.141(b) | Individual #1's physical completed on 5/17/22 was not signed and dated until 6/15/22 and the physical completed on 1/19/23 was not signed until 2/3/23. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | The program specialist called the doctor's office and spoke with the case manager that the physical form needs to be redone all together with accurate information and the form signed by the doctor the day that the physical is completed. |
03/15/2023
| Implemented |
| 6400.141(c)(1) | The most recent physical completed on 1/19/23 indicated that the attached lifetime medical history was not reviewed. | The physical examination shall include: A review of previous medical history. | The director has sent the physical form to the PCP office for Individual #1, to have the lifetime medical history reviewed at the appointment. The physical form will be updated by 3/31/23. |
03/15/2023
| Implemented |
| 6400.141(c)(6) | Individual #1's date of admission was 12/17/22. Their TB test was not completed until 1/19/23. | 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. | A new policy has been written for the intake of a new individual into a residential setting. Included in this policy is that the director will review that a current physical and TB have been completed prior to admission. If the physical and TB have not been completed, the admission will be delayed until information can be given to the director. |
03/15/2023
| Implemented |
| 6400.141(c)(13) | The allergies listed on Individual #1's physical completed on 1/19/23 do not match the allergies identified on Individual #1's face sheet. Individual #1 is listed as being allergic to meat tenderizer. This is not documented on the face sheet or in the ISP. | The physical examination shall include: Allergies or contraindicated medications. | On March 15, 2023, the program specialist took the physical back to the PCP to have the addition of meat tenderizer written on the physical. The director updated the face sheet with meat tenderizer and made sure that the SC was also notified during the ISP meeting on 3/15/23 to have it added to the ISP so that all documents match. |
03/15/2023
| Implemented |
| 6400.181(e)(1) | Individual #1's most recent assessment completed on 1/30/23 did not identify their strengths, needs, or preferences. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | March 13, 2023, the director has corrected Individual #1's assessment along with the other individuals' assessments, to have their functional strengths, needs, and preferences written in each plan and in their own section. |
03/13/2023
| Implemented |
| 6400.181(e)(2) | Individual #1's most recent assessment completed on 1/30/23 did not identify their likes, dislikes, or interests. | The assessment must include the following information: The likes, dislikes and interest of the individual. | March 13, 2023, the director has corrected Individual #1's assessment along with the other individuals' assessments, to have their likes, dislikes and interests written in each plan and in their own section. |
03/13/2023
| Implemented |
| 6400.165(f) | Individual #1 takes psychiatric medications for depression. There is no 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. | 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 program specialist made an appointment for individual #1 with their PCP to complete medication reviews for his psychotropic medication quarterly. A SEEP plan has also been written and given to the SC at the ISP meeting on 3/15/23. |
03/15/2023
| Implemented |
| 6400.165(g) | Individual #1 takes psychiatric medications for depression. Individual #1 has not had a quarterly psych medication review. | 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 program specialist made an appointment for individual #1 with their PCP to complete medication reviews for the psychotropic medication quarterly. |
03/15/2023
| Implemented |
| 6400.213(1)(i) | At the time of the inspection, Individual #1's demographic information documented that Individual #1's religious affiliation was "unknown" indicating Individual #1 was not questioned about their religious affiliation. | Each individual's record must include the following information: Religion. | The director spoke with individual #1 and their family and asked them what they wanted the religion to be documented as; individual #1 reported to the director on 3/6/23 that they had no religion. The face sheet was changed to the individual's preference on 3/6/23. |
03/06/2023
| Implemented |