| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.71 | There were no emergency phone numbers by the living room telephone. | 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.
| The Emergency Contact Telephone List was posted by each phone on 7/27/2021. |
07/27/2021
| Implemented |
| 6400.112(a) | The Fire Drill log was reviewed the home for the past 6months. There was no documentation that a sleep drill was held. | An unannounced fire drill shall be held at least once a month. | An overnight fire drill be conducted by 8/31/2021. |
09/30/2021
| Implemented |
| 6400.144 | Individual 1 did not have as needed (PRN) medications lorazepam, promethazine, Mucinex, and triple antibiotic ointment present in medication box on site during the medication review. | 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.
| The Nurse called the PCP, and a script was sent to the pharmacy on 7/28/2021. All the PRN medications are currently in the home and the MAR was updated accordingly. |
09/30/2021
| Implemented |
| 6400.181(d) | The assessment for individual 1 on February 15, 2021, was not signed or dated by Program Specialist. The Program Specialist signed the Assessment at the time of licensing inspection. | The program specialist shall sign and date the assessment. | The Program Specialist signed and dated the Assessment during on 7/27/2021. |
09/30/2021
| Implemented |