Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.22(d)(1) | In December of 2021 Individual #1 was dispersed $1000. Of that $1000 there is $215.73 which is not accounted for in the provided documentation. | 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. | We were in the process of switching banks and issuing debit cards when some issues with ledgers occurred and our process changed. Moving forward we are doing everything electronically, so all ledgers will have an electronic record that ties back to their bank account for a clear and legible audit trail. |
05/18/2022
| Implemented |
6400.67(a) | The cabinet door under the bathroom sink was damaged. | Floors, walls, ceilings and other surfaces shall be in good repair. | A work order was placed to replace the cabinet door |
05/04/2022
| Implemented |
6400.67(b) | The electrical Outlet in individual #1's room was exposed and damaged. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The electrical outlet was immediately covered and a work order was put in for repair. |
05/04/2022
| Implemented |
6400.112(e) | The fire drills for 742 Woodbrook Road location did not have an overnight fire drill on record from 4/20/21 to 3/24/22 | A fire drill shall be held during sleeping hours at least every 6 months. | An overnight fire drill was completed. |
05/13/2022
| Implemented |
6400.141(a) | According to the documentation found within Individual #1's Record, the individual's latest physical examination occurred on 05/24/2021; however, a record of the prior appointment was unavailable in the record. As such, there is no documentation that the individual received a physical examination annually as required. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Please see attached documentation, also an upcoming physical is scheduled. |
05/13/2022
| Implemented |
6400.142(a) | According to the documentation found within Individual #1's Record, the individual's latest dental examination occurred on 02/23/2022; however, a record of the prior appointment was unavailable in the record. As such, there was no documentation that the individual received a dental examination annually as required. | 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. | This individual needed several clearances from other physicians and family sign off to complete this appointment. Merakey is in the process of getting all needed appointments completed and consents signed. |
05/13/2022
| Implemented |
6400.144 | According to the documentation found within Individual #1's Record, the individual's latest vision examination occurred on 05/06/2021 and the individual's latest hearing examination occurred on 03/22/2022; however, records of the prior appointments were unavailable in the record. As such, there was no documentation that the individual received a vision or hearing examination annually as required. | 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.
| It is essential that appointments be scheduled routinely and as prescribed to ensure the health and safety of the individuals we support. When resident refuses or there is a delay from the medical provider in seeing our resident, it is important that we are providing clear documentation on the events that are occurring. Also, the individual has an upcoming physical appointment, and this will be reviewed to ensure it is documented properly on the physical. In addition, the management team is meeting on 5/13/22 to review how documentation should look prior to any medical appointment and what the physician should complete on the required paperwork |
05/13/2022
| Implemented |
6400.166(b) | Nizoral Shampoo prescribed to individual #1 to be applied once every three days was not logged on April 4th immediately after administration, the log was left blank. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | This was a documentation error as this individual regularly gets his hair washed with this product, and staff confirmed that they completed this task but failed to initial. Management will increase med audits to ensure documentation mistakes or errors do not occur. This is especially important with topicals and liquids that can be less easily verified, and so should be checked more frequently for documentation omissions. |
05/04/2022
| Implemented |