| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(a) | There was no running Hot water in the sink located in bathroom #1 | A home shall have hot and cold running water under pressure. | Facilities visited home and identified the hot water valve under the sink was off and turned it on the same day. |
02/17/2021
| Implemented |
| 6400.77(b) | The First Aid Kit did not contain tape. | 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. | Tape was located in the kit immediately after the Microsoft Teams App disconnected. |
02/17/2021
| Implemented |
| 6400.101 | Access to the balcony was obstructed (snow) was not removed causing it to become hazardous to exit. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Facilities was contacted, and the deck was shoveled the same day. |
02/17/2021
| Implemented |
| 6400.112(d) | Exit time was not listed on fire drill completed on February 3rd 2021. | 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 employe 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. | House Managers were trained on the proper way to complete the fire drill form following the close meeting on 2/18/2021. |
02/18/2021
| Implemented |
| 6400.112(e) | No evidence of a fire drill was held during sleeping hours from Feb 2020 -- Sept 2020. | A fire drill shall be held during sleeping hours at least every 6 months. | : Fire drill was held during sleeping hours on 7/27/2020 at 4:27 AM however, resident was awake upon management¿s arrival to perform the fire drill. Program Specialist will inform house managers at the beginning of each month what week and what shift fire drills will occur to ensure fire drills occur across all shifts and overnight drills are occurring at a minimum every 6 months. |
02/18/2021
| Implemented |
| 6400.167(a)(8) | Individual #2's medication blister pack was dated randomly resulting in licensing not being able to determine if medications were properly distributed. | Medication errors include the following: Improper preparation of the medication. | House Training held on 4/28/2021 via Zoom in conjunction with the start of Merakey¿s 30 day med cycle. Nurse Case manager reviewed the proper way to punch out medication from the blister pack and sign the blister pack. |
04/28/2021
| Implemented |