| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | A bottle of antibacterial hand soap was found on the sink in the main bathroom. Individual 1's plan indicates they are not safe with poisons, and so poisons must be kept locked up. | Poisonous materials shall be kept locked or made inaccessible to individuals. | All poisons are to be locked when not in use. It is the responsibility of the Program Manager to maintain a safe environment for residents. All poisons were removed from cabinets that were unlocked and placed in appropriate locked locations. |
10/31/2022
| Implemented |
| 6400.64(b) | A bug glue trap was found in the oven broiler tray, with black speckled material consistent with pest waste found on the glue. | There may not be evidence of infestation of insects or rodents in the home. | The bug glue tray was removed. The home is treated quarterly by a professional exterminator. |
10/31/2022
| Implemented |
| 6400.66 | There was no operative light on the back porch. The light in the back corner of the basement, near the water pumps, was also non-operational, as was the exterior light outside of the basement door. There was also no light at the top of the basement stairs. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Lighting was replaced at basement backdoor, back porch and light bulbs were replaced where needed. |
10/31/2022
| Implemented |
| 6400.67(a) | The baseboard radiator near the first-floor half bath is broken and falling away from the wall. The blinds on the window on the first floor ½ bath are missing a slat, and the blinds on the left window in the supply room were missing between 11 and 12 slats. The blinds on the right window in Individual 2's room were non-operational---they cannot be raised. | Floors, walls, ceilings and other surfaces shall be in good repair. | There are no radiators at Rose Tree home. Blinds that were broken were replaced. The blinds in Individual 22s bedroom were replaced with curtains. |
11/01/2022
| Implemented |
| 6400.76(c) | Individual 3's bureau has a broken handle on the drawer second from the bottom on the right side. | Furniture shall be comfortable and home-like. | Individual 3 had his bedroom furniture replaced with a new bedroom set. |
06/14/2022
| Implemented |
| 6400.77(b) | The house's first aid kit did not have antiseptic. | 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. | Antiseptic pads were added to all first aid kits. The alcohol pads will remain as it is useful to clean tweezers, scissors, or thermometers. |
11/04/2022
| Implemented |
| 6400.80(a) | The wooden ramp/pathway on the right side of the home was blocked by a drainage pipe hanging down from the roof gutter. It was cleared from the path during the inspection. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | All outside egress paths must be clear of obstructions. Corrected during survey. |
10/31/2022
| Implemented |
| 6400.80(b) | Paneling on the overhanging portion of the roof behind the house is separating from the roof in a spot to the right of the back door. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The overhang and roof area to the right of the back door was repaired. |
11/01/2022
| Implemented |
| 6400.141(c)(4) | Individual 1's 1/18/22 physical does not indicate that a hearing screening was completed, nor does the agency record contain documentation of a hearing exam. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | It is the responsibility of the residential Primary Nurse to schedule and complete all medical appointments. Initial appointment was rescheduled due to COVID exposure. The annual physical is reviewed by the Primary Nurse for completion and follow-up on any recommendations. Hearing evaluation for Individual #1 was completed on 5-31-22. |
05/31/1922
| Implemented |
| 6400.181(e)(12) | Individual 1's 12/3/21 assessment does not contain clear recommendations for specific areas of training, programming and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The Assistant Director of Clinical Services- Program Specialist is responsible to supervise the performance of the Residential Program Specialist. The Assistant Director is also responsible for revision changes needed to comply with 6400 regulations. The assessment has been revised to include clear recommendations for specific areas of training, programming, and services. The Program Specialist were trained on the revision. |
11/04/2022
| Implemented |
| 6400.163(d) | Two medications for Individual 3 were found in an unlocked container in the closet closest to the front door, which was also unlocked: sulfamethoxazole-tmp ds tablets and clindamycin phosp. 1% lotion. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | The residential location was provided a new keypad lock mechanism for the medication closet. This allows all staff to have easy access to medications. Once the door is closed the medications are locked. All staff are responsible to lock medications. |
11/01/2022
| Implemented |
| 6400.163(f) | Omeprazole 20% solution for Individual 3 was found in the refrigerator on the shelf, mixed in with the food, with no lock box or separate container. | Prescription medications stored in a refrigerator shall be kept in an area or container that is locked. | A clear lock box was placed at the home and medications are now locked in the medication lock box and placed in the refrigerator if indicated. |
10/31/2022
| Implemented |
| 6400.163(h) | Individual 1's 325 mg. acetaminophen PRN was expired. The orig. date on the pharmacy label was listed as 3/2/21; the expiration date on the blister pack was listed as 4/2022. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | All medication that is expired is to be removed and given to the nursing department for disposal. The primary nurse is responsible to check in new monthly medications and remove expired medications. The expired medication was removed by the Program Manager. |
10/31/2022
| Implemented |
| 6400.165(b) | Individual 1's MAR calls for Fluticasone prop. 50 mcg spray was listed on the MAR as requiring 1 spray in each nostril daily as needed for congestion or watery eyes, but the pharmacy label calls for 2 sprays in each nostril. | A prescription order shall be kept current. | Individual 1's MAR was revised to read "Fluticasone Prop 50 mcg spray- Instill 2 sprays in each nostril daily as needed for congestion." |
04/26/2022
| Implemented |