| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.107(a) | At the time of inspection, the smoke detector in the home's basement appeared to be active based on the smoke detector's indicator light but was found to be nonfunctional upon testing. The home's smoke detectors were interconnected; the basement smoke detector did not sound when the other alarms were triggered nor when the test button on the basement smoke detector itself was pressed. This smoke detector was inoperable. | A home shall have a minimum of one operable automatic smoke detector provided on each floor, including the basement and attic. | 1. An individual smoke detector was hung in the basement on 1/18/2023. All other interconnecting smoke detectors are functioning.
2. The provider and coordinator received retraining on smoke detector safety as it pertains to the individual's health and safety abilities and risks. The date of the retraining was 2/2/2023. All supporting documentation will be emailed to C. Hadley for review. |
02/07/2023
| Implemented |
| 6500.108(a) | There was no fire extinguisher present in the home's basement at the time of inspection. The provider located a spare fire extinguisher with a current inspection tag on another floor of the home and placed it in the basement prior to the conclusion of the on-site inspection. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | 1. An operable/tagged fire extinguisher was placed in the correct location on 1/18/2023. The basement now has a fire extinguisher.
2. The provider and coordinator received retraining on fire extinguishers as they pertain to the individual's health and safety abilities and risks. The date of the retraining was 2/2/2023. All supporting documentation will be emailed to C. Hadley for review. |
02/07/2023
| Implemented |
| 6500.182(c)(1)(iv) | Individual #1's Individual Record does not contain the individual's religious affiliation or lack thereof. A document titled "Resident Face Sheet" contains an item labeled "Religious Preference," which is blank. Such an item should have an entry using language appropriate to the individual's known lack of religious affiliation or to the individual's declination or inability to provide an answer, e.g., "Atheist", "None", "Unknown", "N/A", "Prefers not to Answer", etc. The complete lack of an entry is reasonably assumed to be an unintentional omission of this information. The individual's religious affiliation could not be located elsewhere within the Individual Record. | Each individual's record must include the following information: Personal information, including: The religious affiliation. | 1. The individual's Residential Face Sheet was amended to reflect the individual's religious preference. The individual's religious preference is unknow due to him not attending church. The face sheet was updated on 1/19/2023.
2. The provider and coordinator received retraining on religious preference and it's importance on 2/2/2023. All supporting documentation will be emailed to C. Hadley for review. |
02/07/2023
| Implemented |
| 6500.133(d) | Individual #1's medications were stored, unlocked, in a medicine cabinet in the home's third-floor bathroom. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | 1. A medication lock box was purchased and placed in the home on 1/19/2023. All of the individual's mediations are currently locked in the medication box.
2. The provider and coordinator received retraining on the need for proper medication storage as it pertains to the individual's health and safety abilities and risks. The retraining occurred on 2/2/2023. All supporting documentation will be emailed to C. Hadley for review. |
02/07/2023
| Implemented |