| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.65 | There was no operational fan in the bathroom. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| The work order for repair of the fan was put in immediately. The Maintenance Department found on 2/13 that the GFI needed to be reset. The GFI was reset and the fan began working. Program Manager/staff are now aware to check the GFI if the fan is not working. The Program Manager will check the fan during his biweekly site checks. |
02/13/2020
| Implemented |
| 6400.76(a) | There were missing knobs on individual #1's dresser. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The dresser was replaced with a new dresser which was purchased on 2/12/2020, (See attachment 15 ) to ensure this does not happen again. Program Managers are to check the dressers for missing knobs/handles (if they have knobs/handles) when at the sites while completing biweekly site checklists. This will be done on a biweekly basis. A community home site checklist( See Attachment 17) is submitted when these checks are completed. |
02/12/2020
| Implemented |
| 6400.144 | The Medication Ensure Max Protein Liquid belonging to individual #1 was not on site, but was signed for on the medication administration record on 02/02/2020. | 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.
| This medication was d/ced, we were waiting for official order from the PCP. Please see attached d/c order (attachment 18 ). Pharmacy has been notified so it can be removed from MAR. Program Managers will complete biweekly site checklist in addition to monthly medication checks to prevent this from occurring in the future.The med certified staff was given a memo (see attachment 14) reminding him of the requirement he was taught during medication administration training. He was trained that medications are to be tripled checked when completing a medication administration. The log should be signed after each medication is administered. He did not complete this step. This was a documentation error. |
02/14/2020
| Implemented |