| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The vent in the ceiling in the bathroom did not maintain clean and sanitary conditions. The vent contained a thick layer of dust. | Clean and sanitary conditions shall be maintained in the home. | The vent was cleaned to remove the dust. |
08/08/2022
| Implemented |
| 6400.68(b) | The hot water temperature in the shower in the home exceeded 120 degrees. The water temperature was 126.1 degrees. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Water temperature was rechecked and confirmed to be under 120 degrees. Facilities staff adjusted the thermostat. |
09/14/2022
| Implemented |
| 6400.101 | Individual #4's bedroom door was not unobstructed. There was a lock on the doorknob and the lock was placed on the outside of the individual's door inhibiting the individual's ability to open the door from the inside if the door were locked. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The lock was immediately removed. |
08/04/2022
| Implemented |
| 6400.111(f) | The fire extinguisher located in the garage of the home was not inspected and approved annually by a fire safety expert. The fire extinguisher was last inspected in 4/21. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | The outdated fire extinguisher was removed by the house supervisor and replaced by a fire extinguisher that was up to date with inspection. |
08/04/2022
| Implemented |
| 6400.112(d) | Individual #4, Individual #10 and Individual #11 did not evacuate the home within 2 1/2 minutes during the fire drill conducted on 11/16/21 at 1PM. The evacuation time was 2 minutes and 40 seconds. There were no issues documented that prevented the evacuation to occur in the allotted time. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | Staff will be trained by the behavior specialist on best practices around safe and effect evacuation of the individuals. |
09/16/2022
| Implemented |
| 6400.113(a) | Individual #4, Individual #10 and Individual #11 did not receive fire safety training upon moving into the home. Individual #4, Individual #10 and Individual #11 moved into the home on 10/21/21. All individuals received fire safety training for 2021 in the previous home on 3/2/21. Individual #4 did, Individual #10 and Individual #11 did not receive fire safety training relative to the new home until 2/24/22. | 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. | All individuals were trained on fire safety training. |
09/16/2022
| Implemented |
| 6400.32(r)(1) | Individual #4, Individual #10 and Individual #11 have locks on the individual's bedroom doors, however the locks on the doors are "coin key" locks and do not permit the individual's to be able to lock and unlock the bedroom doors. "Coin key" or "pin locks" are not acceptable to comply with this regulation as they do not maintain the necessary level of privacy and security to the indivdiuals. | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | The team met to discuss locks for individual #4, #10 and #11.
Locks were deemed inappropriate and/or unwanted by the individual.
The ISP was updated to reflect such information. |
09/01/2022
| Implemented |
| 6400.165(c) | Individual #4 is prescribed Flonase 0.05% Nasal Spray, instill 1 spray into each nostril once daily at 8am. The prescription was last filled on 5/27/22 and contained 120 metered sprays (60-day supply based on the prescribed dosage). The medication would have been due to be refilled on 7/27/22 based on the last refill dated. The medication is documented as administered as prescribed; however, the bottle was half full. | A prescription medication shall be administered as prescribed. | Staff will be retrained on 9/22/2022 to ensure they know how to administer the nose spray. |
09/22/2022
| Implemented |
| 6400.165(g) | Individual #4's medication reviews completed on 3/23/22 and 6/15/22 did not include the name or dosage of the medication. | 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. | Haven House was contacted for review forms stating that each review included the medication prescribed, reason for prescribing and the reason to continue. |
09/16/2022
| Implemented |
| 6400.166(a)(13) | Individual #4 is prescribed Buspirone HCL 5mg tablet, take one tablet by mouth 2x daily at 8AM and 8PM (anxiety). The medication record did not include the name and initials of the person administering the medication at 8PM on 8/3/22. | 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. | House Supervisor retrained staff on how to fill out a MAR properly. |
08/18/2022
| Implemented |