| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | The window in bedroom #1 would not stay in the open position when opening. | Floors, walls, ceilings and other surfaces shall be in good repair. | Last year we implemented a plan to address the environmental citations. As a result of this plan, we had about a 35% decrease in physical plant citations. We will continue with the same plan as indicated below.
Three times per year an unannounced walk through/inspection will be conducted in all licensed homes by a Residential Director and/or Assistant Vice President of Residential Program. A plan of correction along with a compliance score sheet will be issued to the building manager who will have 30 days to respond and correct all areas that are not in compliance with regulatory standards. The scores will be used to develop a performance improvement plan for the assigned Residential Manager. Residential Directors will not complete unannounced inspection in their assigned programs. |
03/16/2023
| Implemented |
| 6400.77(b) | The First Aid Kit did not contain 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. | Nursing staff will continue to check Emergency Equipment which includes First Aid kit on weekly basis and document completion as well as replenish any supplies used. Nurse manager will review completed checklist monthly. |
03/17/2023
| Implemented |
| 6400.141(c)(6) | Tuberculin skin testing with negative results were not completed every 2 years for individual 1. The previous test was done on 04/13/2019 and not completed again until 01/11/2022. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Medical Assistants will review MAR's prior to all scheduled Annual Physical Examinations for the requirement to conduct tuberculin testing, EKG, and/or prostate examinations. |
03/10/2023
| Implemented |
| 6400.181(a) | Individual 1 did not have an assessment completed annually, previous assessment was completed on 11/04/2021 and current assessment was not completed until 01/03/2023. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Assessment timelines, expectations and the importance of meeting regulatory requirements will be reviewed with the Case Manager by the Assistant Director of Case Management. |
03/31/2023
| Implemented |