Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.64(a) | The bathroom showers located in the home had residue consistent with dirt and mildew along the seams of the tile near the base of the showers. The bathrooms also had and odor consistent with urine throughout. The top shelf of the refrigerator had two food items not properly covered and not dated. | Clean and sanitary conditions shall be maintained in the home. | All bathroom showers were cleaned by residential coordinator on 8/31/2022 (Attachment #35). Delta maintenance replaced the caulk in the shower on 9/26/2022. |
08/31/2022
| Implemented |
6400.64(e) | Two trash cans located in the garage did not have lids on them. One was filled with trash, the other can had recyclables. Both cans were in regular use without lids. Round lids were located on the floor of the garage, however the can for trash was rectangle. | Trash receptacles over 18 inches high shall have lids. | Outdoor trashcans were corrected by chief program director on 9/24/2022 (Attachment #36). |
09/24/2022
| Implemented |
6400.67(a) | There were damaged floor thresholds at the exits from the living room. The hallway wall on the main level near the bathroom had scuffing that caused paint and wood to be chipped. The sink in the main level bathroom was cracked and repaired with glue. The front left burner of the kitchen oven was damaged and bent inward toward the stove pan. | Floors, walls, ceilings and other surfaces shall be in good repair. | Damaged floor thresholds were repaired by Delta maintenance on 9/26/2022 (Attachment #37). Hallway was repainted by Delta maintenance on 9/8/2022 (Attachment #38). Sink was replaced by Delta maintenance on 9/12/2022 (Attachment #39). Kitchen stove was replaced by Delta maintenance on 9/12/2022 (Attachment #40). |
09/26/2022
| Implemented |
6400.68(a) | The home did not have hot running water. The water at all water sources reached a maximum temperature of 76.1 degrees Fahrenheit. The hot water heater was not functioning. | A home shall have hot and cold running water under pressure. | Maintenance adjusted the thermostat on the water heater and the water temperature is now 109° (Attachment #41). |
09/09/2022
| Implemented |
6400.81(k)(2) | There was no bed frame for the mattress in Individual 1's bedroom. A new bedframe was ordered after inspection on 8/31/2022. | In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. | Individual 1 received a new bed frame on 8/31/2022 (Attachment #43). |
08/31/2022
| Implemented |
6400.82(f) | The bathrooms in the home did not have paper or hand towels. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Residential coordinator placed paper towels in the bathroom 8/30/2022 (Attachment #44). |
08/30/2022
| Implemented |
6400.144 | The health service of testing sugar levels weekly on Mondays with accu-check was not fully logged for Individual 1. The Glucose level checks were marked as completed in August but the levels were not recorded onto the medication record from the device . The diabetes protocol was not located in the individual's binder or file in the office area to notate if recording blood sugar levels were needed. | 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.
| The residential coordinator contacted the doctor¿s office via phone on 8/31/2022 to request the diabetes protocol. The diabetes protocol sent by the doctor on 9/6/2022 (Attachment #45) was vague and as such, on 9/6/2022 the residential coordinator requested via phone call an updated protocol to specify what follow through is needed based on the reading. Doctor¿s office was contacted via phone again on 9/23/2022 and 9/26/2022 as no updated protocol has been received.
After further follow up, the chief program office discovered that the glucose checks were changed to daily, no longer weekly, with the 9/6/2022 order however the residential coordinator and direct support professionals were not completing the checks daily. As a result, on 9/23/022 the Delta incident management coordinator entered a Neglect incident into EIM (9094639) that will be thoroughly investigated by a Delta certified investigator. Delta management will review the investigation, make recommendations for corrective follow up, and follow through that all corrective actions are completed by October 31, 2022. On 9/23/2022 the incident manager requested that the glucose monitor be replaced, pharmacy called, staff trained on new glucose monitor and tracking, and that his team would be notified. A new glucose monitor was purchased by the chief program office on 9/26/2022 and taken to the home the same day. The residential coordinator trained all house staff on daily monitoring on 9/26/2022 (Attachment #46). The pharmacy was contacted by regional director via phone on 9/23/2022 to request the MAR be updated with daily checks. The support coordinator was contacted via email by regional director on 9/23/2022 (Attachment #47). |
09/26/2022
| Implemented |
6400.32(r) | The doors to Individuals 1, 2, and 3's bedrooms did not have the ability to be locked. | An individual has the right to lock the individual's bedroom door. | The individuals and guardians for the residents in this home were contacted by the residential coordinator on 9/23/2022 and all stated they do not want locking doorknobs on the bedroom doors. This communication has been shared with the support coordinators to include in the individuals¿ ISPs (Attachment #48). |
09/23/2022
| Implemented |