| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.111(a) | There was no fire extinguisher located in the basement area. There were 7 steps down to a partial basement. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | Monthly fire drills and equipment checks will continue to be made to ensure appropriate equipment is present. |
01/27/2023
| Implemented |
| 6400.144 | Sore throat spray to be given 2 sprays every 3 hours as needed was not located on site, not accessible for individual 1 to use if needed. Medication was still notated in the record as an active as needed medication. | 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.
| Residential staff will complete cart checks weekly. Residential supervisor will complete random cart checks weekly. Nurse will review cart checks monthly. |
03/31/2023
| Implemented |
| 6400.165(c) | One daily vitamin was not given to individual 1 on 1/3/2023 and Polyeth glyc powder was not administered on 1/5/2023 and 1/24/2023. The morning AM doses were not administered as prescribed. It was notated on the record as medication not available at the time of administration. | A prescription medication shall be administered as prescribed. | Residential staff will complete cart checks weekly. Residential supervisors will do random cart checks weekly in all homes DSP's administer medications. Nurse will randomly review cart checks monthly. |
03/31/2023
| Implemented |
| 6400.166(b) | Medications Briviact 50mg, Lithium Carb 300mg capsules and Lorezapam were not signed immediately after administration on the 8th and 21st of January for individual 1. The medication record was blank. Pill count was verified that medication was administered but not logged. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Residential supervisor will check for missing signatures weekly. Nurse will do random missing signature checks weekly. Nurse manager will review missing signature checks monthly. |
03/31/2023
| Implemented |