| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(b) | In the basement floor area, the sump pump was not operating, therefore water puddles were on the floor. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Program Coordinator contacted the Landlord on 7/26/2022. The sump pump was repaired and is operational again |
07/27/2022
| Implemented |
| 6400.70 | The land line phone was not operating at the time of inspection. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| Verizon was called on 7/22/2022 and the line was rebooted. The phone line is working. |
10/07/2022
| Implemented |
| 6400.77(b) | The First Aid kit did not contain the following items: the first aid manual, and the thermometer. | 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. | Program Coordinator purchased a new thermometer and put in kit on 7/27/2022. The first aid manual was available during inspection and shown to the inspector, but she said that because it was not in the kit it was the problem and that she wanted the small booklet that came with the first aid kit. |
07/27/2022
| Implemented |
| 6400.81(k)(5) | Individual's #1 bedroom was missing a closet. | In bedrooms, each individual shall have the following: Closet or wardrobe space with clothing racks and shelves accessible to the individual. | As per the individual's family request, the individual preference to have his own bathroom was completed. The home was remodeled to accommodate this preference. The individual also has a history of removing clothing and other items from his closet. The removal of items and putting them on the floor is a safety hazard for him as he has total blindness/deafness. On 9/29/2022, the Executive Director sent a Waiver Request Form to ODP regarding the individual's mirror safety concerns. |
10/31/2022
| Implemented |
| 6400.81(k)(6) | Individual's #1 bedroom was missing a mirror. | In bedrooms, each individual shall have the following: A mirror. | The individual¿s team agreed that having mirror in his bedroom was unsafe during his ISP 0n 8/17/22. On 8/17/22, the individuals ISP was held, and his team agreed that having a mirror in the individual¿s room was a safety risk due to his behavior problems. This information was added in his ISP and annual assessment. On 9/29/2022, the Executive Director sent a Waiver Request Form to ODP regarding the individual's mirror safety concerns. |
08/17/2022
| Implemented |
| 6400.110(a) | The smoke alarm on the 3rd floor did not operate when the system was tested. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | A call was made to Unifire to schedule service. On 9/28/22. Technician scheduled to make repairs by 10/5/2022. |
10/05/2022
| Implemented |
| 6400.181(e)(10) | Individual #1's assessment did not contain a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | Lifetime Medical History has been sent to the team. |
10/04/2022
| Implemented |
| 6400.181(e)(14) | Individual #1's annual assessment does not include individual's knowledge of water safety or the ability to swim. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | On 8/4/22, the assessment was updated and sent to his Team. |
08/04/2022
| Implemented |
| 6400.163(a) | Individual #1 Medication Ammonium Lactate 12% cream was missing its original container. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | 7/22/22, a new tube of the medication was sent to the home, and it was shown to the Licensing Representative while at the home. However, the Program Manager will ensure that the medications are always on site and in the original container. |
10/06/2022
| Implemented |
| 6400.165(c) | Individual #1 prescribed medication DHS-Sal Shampoo label read the medication was to be administered every other day, however the medication administration record said to administer daily. | A prescription medication shall be administered as prescribed. | 7/27/22 The script was verified with the pharmacist to ensure that the correct information was on the label. The MAR was corrected, and staff were retrained on the administration of the medication as prescribed. |
07/31/2022
| Implemented |
| 6400.165(g) | Individual #1 has not received quarterly psychotropic medication reviews. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | 7/24/22 the Program Coordinator called Merakey and could not secure an appointment due to lack of practitioners. The Program Coordinator called Riddle Psych Clinic and was informed that they would accept new clients in mid-7/24/22 the Program Coordinator called Merakey and could not secure an appointment due to lack of practitioners. The Program Coordinator called Riddle Psych Clinic and was informed that they would accept new clients in mid-September 2022. On 9/26/22 The Program Manager called Riddle and the individual was placed on a waiting list. On 9/28/22 the Manager called Omni Health Services and there is a 6 months waiting period, Family & Community Services of Delaware County has an 8-9 months waiting period, and Life Path said to call in January. However, an appointment was made today with Merakey for 11/17/2022 at 2:55PM |
10/31/2022
| Implemented |
| 6400.181(f) | Individual #1's assessment was not sent to team at least 30 days prior to ISP meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Program Coordinator will send the assessment to the Team a month prior to the ISP meeting. The Program Coordinator will provide documentation to the Executive Director indicating the Assessment was sent 30 days prior to the ISP Meeting. |
09/30/2022
| Implemented |
| 6400.183(c) | Individual #1's file did not contain ISP meeting participants and sign in sheet. | The list of persons who participated in the individual plan meeting shall be kept. | The ISP was held virtually. The sign sheet was attached, and it included the names of those who were in attendance. |
09/17/2022
| Implemented |