| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(b) | A space heater in an office area is hanging from the ceiling by one bolt, and is not securely attached which presents a safety hazard. | (b) Floors, walls, ceilings and other surfaces shall be free of hazards. | Maintenance staff have removed the space heater from the basement office. |
02/19/2014
| Implemented |
| 6400.77(b) | The first aid kit was missing a pair of tweezers. | (b) A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served.
| Tweezers were put back in the first aid kit. [Per conversation with provider on 3/20/14, a representative has been assigned to check the contents of the first aid kit monthly. (CHG 3/20/14)] |
01/31/2014
| Implemented |
| 6400.144 | Individual #1 is ordered Glucose tablet, 4 grams, chew and swallow one tablet if glucose reading is below 60 or if symptomatic. A review of the registered blood sugar readings from Individual #1's glucometer showed that his/her blood sugar was 39 on 1/5/14 at 6:46 PM. The Glucose tablet was not administered to the individual at the aforementioned time. | 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.
| Doctors orders have been revised to reflect protocols which follow best practice. Glucose tabs are no longer ordered through doctors orders and supplied by the pharmacy, thus requiring MARS. Doctor's protocol now indicates several options for staff to follow in correcting blood sugars of less than 70. These orders are reflective of training staff receive in their insulin injection training for diabetics who require insulin. |
02/19/2014
| Implemented |
| 6400.181(f) | Individual #1's Assessment, which was completed on 2/10/2013, was not provided by the program specialist to the supports coordinator, and team members, at least 30 calendar days prior to the ISP meeting. | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| Supports Coordinator has informed Program Specialist she did receive Assessment through e-mail. Moving forward, Program Specialist will retain e-mail confirmation of providing assessments to Supports Coordinators. |
01/31/2014
| Implemented |
| 6400.186(a) | Between the dates of 8/19/2013 and 1/27/2014, an ISP review was not completed. | (a) The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP.
| Program Specialist will assure compliance moving forward by including reminder due dates in her Outlook calendar. |
02/24/2014
| Implemented |
| 6400.213(1)(i) | None of the records included the individuals' sex, to denote the individuals' gender. | Each individual's record must include the following information:
(1) Personal information including:
(i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.
| Gender has been added to all consumers' face sheets. |
01/31/2014
| Implemented |