| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(b) | Surfaces shall be in good repair. Multiple ceiling tiles located in the basement had what resembled water or brown/mildew stains on them, and approximately 3 of the ceiling tiles in in the basement appeared to be buckling. 2 of the ceiling tiles located inside the doorway of Individual #6's bedroom appeared to be buckling and cracking away from the ceiling. The curtain located on the right window in the kitchen was ripped off leaving just the corner piece remains on the right-hand corner of the rod of what was once the curtain. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Ceiling tiles were replaced in the basement and in individual #6's bedroom. However the facilities director is asking that the landlord repair it further with dry wall. This will be completed 10/15. |
10/15/2022
| Implemented |
| 6400.68(b) | The water temperature in the main bathtub measured at 130.8 ° F. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Water temperature was checked and confirmed to be at or below 120 by facilities director. The thermostat was adjusted to ensure the temperature will remain. |
09/14/2022
| Implemented |
| 6400.72(b) | Screens shall be in good repair. The screen in the bottom right kitchen window had a tear in it approximately the size of a quarter. | Screens, windows and doors shall be in good repair. | Screen was fixed and installed on 8/30/2022. |
08/30/2022
| Implemented |
| 6400.112(c) | The fire drill records for the fire drills conducted on 8/29/21 at 2:00, 9/15/21 at 1:15, 2/17/22 at 2:43, and 5/24/22 at 1:38 did not document the designation of AM / PM for the time that the drills were completed. The fire drill record for the fire drill conducted on 4/19/22 did not document the time the drill was complete as this section of the form was left blank. The fire drill record for the fire drill conducted on 5/24/21 did not document the amount of time it took for evacuation as this section of the form was left blank. | 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. | New fire drill logs were developed that clearly indicate what is required and when. These were sent to the team on 9/15/2022. |
09/15/2022
| Implemented |
| 6400.112(e) | A fire drill shall be held during sleeping hours at least every 6 months. An asleep fire drill was completed on 1/17/22 and one has not been completed since. This exceeds the requirement. | A fire drill shall be held during sleeping hours at least every 6 months. | New fire drill logs were developed that clearly indicate what is required and were sent to the team on 9/15/2022 the the CLA director. |
09/15/2022
| Implemented |
| 6400.141(c)(3) | Individual #3's physical exam dated 11/5/21 did not include Immunizations as this section of the exam was left blank. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Immunizations will be placed on physical form. House Supervisors, the Agency nurse, and the CLA Director will ensure all documentation is included for each physical exam. |
09/15/2022
| Implemented |
| 6400.141(c)(11) | Individual #3's physical exam dated 11/5/21 did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work as this section of the exam was left blank. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | Agency Nurse and House supervisor will ensure that each section is filled in completed entirely even if the section is an N/A. Agency Nurse verified there was no need for blood work and attached the medication list. |
09/19/2022
| Implemented |
| 6400.141(c)(15) | Individual #3's physical exam dated 11/5/21 did not include special instructions for the individual's diet as this section of the exam was left blank. | The physical examination shall include:Special instructions for the individual's diet. | Agency Nurse verified that his diet is normal. This will be added to physicals moving forward. |
09/19/2022
| Implemented |
| 6400.32(r)(5) | Individual #3's and Individual #5's bedroom doors had "coin key "locks on it, and Individual #6's bedroom door had a "pin key" lock on it, and there wasn't a key to unlock the door. Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door. A "pink key or "coin lock" is not acceptable to comply with this regulation. | Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door. | Individual #3 will get a key pad lock, #5 and #6 will have key locks. All will be installed by the facilities manager. |
09/30/2022
| Implemented |
| 6400.46(d) | Direct service workers shall be trained within 6 months after the day of initial employment by individual certified as a trainer. Staff #5's date of hire is 3/30/21 and they received their training on cardio-pulmonary resuscitation and first aid until 10/21/21. This exceeds the requirement. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | After further review it was noted that Staff #5 was a rehire with an original hire date of 3/26/2018 which caused her to be late since her hire date was not changed on our spreadsheet. This has been fixed and further rehires will be updated. |
09/19/2022
| Implemented |
| 6400.165(c) | Individual #3 is prescribed Tamsulosin HCL 0.4 mg caps, 1 capsule by mouth daily with dinner @ 5pm. There were no initials on the Medication Administration Record (MAR) for a 5pm administration of the medication on 8/3/22, and the medication remained in the blister pack for 8/3/22 administration to indicate that the medication was not administered as prescribed. | A prescription medication shall be administered as prescribed. | An EIM was entered for the medication error that occurred on 8/3/2022. |
09/15/2022
| Implemented |
| 6400.165(g) | Individual #3 had psychiatric medication reviews on 2/3/22, 4/28/22, and 7/21/22 and the forms used did not include documentation on the reason for prescribing the mediation and the necessary dosage. | 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. | Agency nurse contacted physician to have this updated. She will ensure all reviews moving forward are completed properly. |
09/19/2022
| Implemented |
| 6400.166(a)(2) | Individual #3's August 2022 Medication Administration Record (MAR) did not include the following prescribers for medications that were administered: Dr. Charlene Gondon, Dr. Nicholas Tatalias, Dr. Craig Hartigan, and Dr. Michaela Garland. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | Prescribing doctors were added to the MAR by House Supervisor |
08/05/2022
| Implemented |
| 6400.166(a)(13) | Individual #3's prescribed Atorvastatin 40 mg tablet, take 1 tablet by mouth daily at 8pm. The 8/3/22 8pm administration on the Medication Administration Record (MAR) did not include the initials of the person administering the medication. The medication appears to have been administered as they were removed from the blister pack. | 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. | A training will be completed with staff on properly completing an MAR. |
09/15/2022
| Implemented |