| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.77(b) | There was no medical tape present in the first aid kit. | 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. | Based on the licensing review of November 9-10, 2022, the CLA Director, on 11/14/22, retrained the Site Supervisors responsible for the sites, as well as the Assistant Directors about the importance of ensuring that the First Aid Kit is properly stock with tape and all regulatory items. |
11/10/2022
| Implemented |
| 6400.81(k)(6) | There was no mirror present in the bedroom of Individual 1. | In bedrooms, each individual shall have the following: A mirror. | Based on the licensing review of November 9-10, 2022, the CLA Director, on 11/14/22, retrained the Site Supervisors responsible for the sites, as well as the Assistant Directors about the importance of ensuring that every individual¿s bedroom has a mirror as well as other regulatory items. |
11/10/2022
| Implemented |
| 6400.141(c)(10) | Individual 1: On the 7/7/2022 Physical exam form, the area designated to note if the individual is free from communicable diseases was left blank. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | Based on the licensing review of November 9-10, 2022, the CLA Director, on 11/14/22, retrained the Nurse Manager and Health Care Office Manager about the importance of ensuring that the individual¿s physical clearly indicates that they are free of communicable disease per regulatory guidelines. (It was noted by the Nurse Manager that she had gotten this corrected by the doctor¿s office when it occurred, but accidently sent in the wrong copy to the licensors). The Nurse Manager is responsible to ensure all medical appointments/documentation are regulatory compliant. |
11/10/2022
| Implemented |
| 6400.141(c)(12) | Individual 1: Physical limitations and restriction from activities section left blank on the 7/7/2022 physical exam. | The physical examination shall include: Physical limitations of the individual. | Based on the licensing review of November 9-10, 2022, the CLA Director, on 11/14/22, retrained the Nurse Manager and Health Care Office Manager about the importance of ensuring that the individual¿s physical clearly indicates the physical limitations. (It was noted by the Nurse Manager that she had gotten this corrected by the doctor¿s office when it occurred, but accidently sent in the wrong copy to the licensors). The Nurse Manager is responsible to ensure all medical appointments/documentation are regulatory compliant. |
11/10/2022
| Implemented |