| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.63(a) | Hot water in the bathroom sink was measured at 137.3 degrees; in the kitchen sink, 139.6 degrees. | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | The Maintenance Department was immediately contacted, and the water temperature was adjusted on 08/3/2023 (Picture attached of water temp). |
09/30/2023
| Implemented |
| 6400.68(b) | Hot water in a bathroom shower was measured at 129.8 degrees. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The Maintenance Department was immediately contacted, and the water temperature was adjusted on 08/3/2023 (Picture attached of water temp). |
09/30/2023
| Implemented |
| 6400.141(c)(4) | Individual #6's file does not contain verification of completion of their 5/3/23 annual vision appointment. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | The appointment was scheduled for 08/16/2023 (proof of appt). (Attached appointment paperwork and next appt scheduled) |
09/30/2023
| Implemented |
| 6400.144 | Individual #6's kit was missing their PRN clobetasol 0.05% ointment and PRN albuterol HFA 90 mcg. inhaler. | 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.
| For corrective action and clarification purposes, individual #6 kit was missing PRN albuterol HFA 90 mcg inhaler at the time of review, due to individual #6 being out in the community and carrying it on person. Due to the need for this medication to be available for them to use as needed, they carry it with them when they leave the home. The individual is self-medicating and verbalizes understanding of the proper use of their inhaler. The ISP's attachment demonstrates their competence in handling their medications, as they is self-medicated, thus negating the necessity for having the inhaler out of the medication box.
The clobetasol ointment 0.05% was determined that the individual no longer uses and in the process of getting discontinued by the attending Physician. |
09/30/2023
| Implemented |
| 6400.181(e)(12) | Individual #6's 4/14/23 assessment does not contain recommendations for specific areas of training, programming and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The assessment for individual #1 was documented and revised on 08/04/2023. Future assessments to reflect the recommendations for specific areas of training, programming, and services. |
10/31/2023
| Implemented |
| 6400.216(a) | Program books containing individuals' personal information were found unlocked on a shelf in the house office. The office door does not have a lock mechanism. | An individual's records shall be kept locked when unattended.
| The office door was repaired on 8/4/2023 by our Maintenance Team and a new door knob with a locking mechanism was replaced (see attachment of doorknob). |
09/30/2023
| Implemented |
| 6400.163(g) | Individual #6's PRN ibuprofen was not stored in an organized manner under proper conditions of sanitation. Pills had been removed from the blister pack and partially taped back in. When the blister pack was removed from the kit for review, medication fell out of it. | Prescription medications shall be stored in an organized manner under proper conditions of sanitation, temperature, moisture and light and in accordance with the manufacturer's instructions. | The medication for individual #6 PRN ibuprofen is intact and sealed packed by the pharmacy on 09/08/2023. (Picture of blister packet) |
09/30/2023
| Implemented |
| 6400.213(1)(i) | Individual #6's file does not contain a record of identifying marks. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | On 08/04/2023 the Emergency Data Form was updated identifying she does not have any identifying marks. (IDF form) |
09/30/2023
| Implemented |