| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.65 | On 8/13/13, the bathroom in the basement did not have a window or mechanical ventilation. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| A battery operated fan was purchased and placed in the basement bathroom on 8/13/2013 verification was provided to the surveyor prior to the exiting meeting. An exhaust fan was then installed on 8/27/13 in that bathroom. Verification will be scanned and e-mailed. |
09/04/2013
| Implemented |
| 6400.71 | On 8/13/13, the telephone in the basement did not have emergency numbers posted on or near the phone. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| Emergency numbers were installed on phone on 8-13-13. Verification was provided to the surveyor prior to the exiting meeting. |
09/04/2013
| Implemented |
| 6400.141(c)(6) | Individual #1 did not have Tuberculin skin testing every 2 years. Individual #1 had testing completed on 1/27/10 and not again until 4/19/12. | (6) Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted.
| Nursing staff will assure all required testing is completed within timelines. 3 individual's physicals will be scanned and e-mailed to verify that timelines are being met. |
09/04/2013
| Implemented |
| 6400.164(b) | The following medications administered to Individual #1 on 8/11/13 at 2:00PM were not logged immediately after administration: Lithium Carbonate 300mg, give 1 capsule by mouth three times a day, and Guanfacine 1mg, give 1 tablet by mouth three times a day. | (b) The information specified in subsection (a) shall be logged immediately after each individual's dose of medication.
| Documentation was completed on 8/13/13 and verification was provided to the surveyor prior to exiting. RPS staff will assure medications are logged immediately after administration by providing oversight to process and reviewing documentation at home visits. |
09/04/2013
| Implemented |