| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(c) | The fire drills conducted on 2/21/2021 and 9/18/2020 did not have a documented evacuation time. The fire drill conducted on 3/01/2021 did not have a documented time that the drill was conducted. The fire drill conducted on 10/10/2020 did not have an exit route identified. The of fire drill conducted on 4/07/2021 had a recorded evacuation time of 15 minutes, which exceeds the maximum evacuation time by 12 and 1/2 minutes, but no problems encountered were recorded to explain the extended evacuation time. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | All staff assigned to this location will be retrained on the agency procedure for Conducting and Recording a Fire Drill and Fire Safety Training. The Coordinator of the assigned area will review the fire drill record each month prior to the end of the month to ensure fire drills have been completed, meet all licensing standards and documented as outlined in procedure. If the coordinator responsible for review finds an area of non-compliance another drill will be conducted within the month noted to ensure all residents are able to evacuate and documentation is completed as required. |
09/15/2021
| Implemented |
| 6400.112(d) | The fire drill conducted on 4/07/2021 had a recorded evacuation time of 15 minutes, which exceeds the 2 1/2 minute evacuation time limit required by regulation. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employee of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | All staff assigned to this location will be retrained on the agency procedure for Conducting and Recording a Fire Drill and Fire Safety Training. The Coordinator of the assigned area will review the fire drill record each month prior to the end of the month to ensure fire drills have been completed, meet all licensing standards and documented as outlined in procedure. If the coordinator responsible for review finds an area of non-compliance another drill will be conducted within the month noted to ensure all residents are able to evacuate and documentation is completed as required. |
09/15/2021
| Implemented |
| 6400.166(a)(13) | Individual #1's Medication Administration Record (MAR) for the month of June 2021 are missing the initials of the person administering medication for the following medications and times: Divalproex DR 500 mg. on 6/16/2021 at 9PM, Chlorpromaz 0.5 mg. on 6/14/2021 and 6/19/2021 at 12PM, Clonazepam 2 mg. on 6/20/2021 at 8pm and 12PM, and Clonzapine 100 mg. on 6/16/2021 at 9PM. | 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. | The staff members responsible for this error will complete a remediation training on Mediation administration and appropriate documentation of medication administration. |
09/01/2021
| Implemented |