| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Individual 1's ISP indicates poisons must be kept locked because they do not understand their danger. Poisons were found unlocked in a cabinet in the garage, including Carbona ceramic cooktop cleaner, Pure Power glass cleaner, aerosol oven cleaner, and Soft Scrub cleaner and deodorizer. A lock was placed on the cabinet at point of inspection. Two bottles of hydrogen peroxide were also found in an unlocked pantry closet in the kitchen. The bottles of peroxide were moved to a locked cabinet during the inspection. | Poisonous materials shall be kept locked or made inaccessible to individuals. | All poisons were locked on 8/29/2022 by residential coordinator (Attachment #s 5, 6 ). |
08/29/2022
| Implemented |
| 6400.62(d) | Food and poisons were found stored together in the kitchen pantry closet. Two bottles of hydrogen peroxide along with the house's first aid kits were stored on a shelf alongside coffee and snack pudding cups. The bottles of peroxide were moved to a separate locked cabinet during the inspection. | Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces. | All poisons were locked on 8/29/2022 by residential coordinator (Attachment #s 5, 6). |
08/29/2022
| Implemented |
| 6400.216(a) | Program books for all three individuals who reside in the home were found on an open shelf in the unlocked office area. The books contained sensitive materials, such as medical records. | An individual's records shall be kept locked when unattended.
| A new lock box was purchased and brought to the home by Delta maintenance on 9/23/2022. All confidential materials were safely stored in the new lock box on the same date (Attachment #7). |
09/23/2022
| Implemented |
| 6400.166(a)(13) | Individual 1's MAR was not signed by the staff who administered their Carb/Levo ER tablet (50 -- 200 mg) on 8/26/22 at 8AM. The medication had been administered per their 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. | Residential coordinator updated the MAR with corrections on 8/30/2022 (Attachment #8). The initials of the staff who administered the medication were added to the MAR and the box was circled in red. An explanation stating the medication was administered and the staff mistakenly did not initial at the time the medication was given. Residential coordinator contacted staff to review medication documentation on 8/30/2022. |
08/30/2022
| Implemented |