| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | The blinds on the window of Individual #2 bedroom were extremely difficult to raise and in need of being changed. | Floors, walls, ceilings and other surfaces shall be in good repair. | A work order has been entered with our facilities team for new blinds, and they will be installed once the new blinds arrive.
All program managers and other personnel responsible for checking physical site will be retrained on regulation6400.67(a) and minimum of one safety round (see Appendix B) will be completed for each program area every two weeks. Any area in a home that is identified on the safety round form as not being in good repair will be reported to our facilities department immediately for timely correction.
Person Responsible: Program Manager, facilities personnel, department director |
11/11/2020
| Implemented |
| 6400.72(a) | There were no screen in windows in the bedroom of Individual #2. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | A work order has been submitted for installation of screens for the bedroom of individual #2.
All program managers and other personnel responsible for checking physical site will be retrained on regulation6400.72(a) and minimum of one safety round (see Appendix B) will be completed for each program area every two weeks. Any window in a home that is identified on the safety round form as not being securely screened will be reported to our facilities department immediately for timely
correction.
Person Responsible: Program Manager, facilities personnel, department director |
11/11/2020
| Implemented |
| 6400.73(a) | The handrail leading down to the driveway from the deck became detached when handled during inspection. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | The handrails leading down to the driveway form the deck were secured on the date of inspection.
All program managers and other personnel responsible for checking physical site will be retrained on regulation 6400.73(a) and minimum of one safety round (see Appendix B) will be completed for each program area every two weeks. Any handrail that is identified on the safety round form as not being well-secured will be reported to our facilities department immediately for timely correction.
Person Responsible: Program Manager, facilities personnel, department director |
11/11/2020
| Implemented |
| 6400.80(b) | The deck leading off of Individual #3 bedroom, the handrails were loose on both sides facing the house. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The handrails to the deck leading off od individual #3's bedroom were secured on the date of inspection.
All program managers and other personnel responsible for checking physical site will be retrained on regulation 6400.80(b) and minimum of one safety round (see Appendix B) will be completed for each program area every two weeks. Any handrail that is identified on the safety round form as not being well-secured will be reported to our facilities department immediately for timely correction.
Person Responsible: Program Manager, facilities personnel, department director |
11/11/2020
| Implemented |
| 6400.141(a) | Individual #1 current physical was dated 7/16/2020 and the prior physical was dated 1/10/19 | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #1 will have an annual physical scheduled prior to 7/16/20 to ensure a physical examination occurs annually.
To prevent future recurrence, all healthcare professionals responsible for scheduling medical appointments will be retained on regulation 6400.141(a) during a healthcare team meeting. this will be documented on the team meeting minutes.
Person responsible: primary care nurse, healthcare coordinator, nurse manager |
11/11/2020
| Implemented |
| 6400.141(c)(11) | Individual #1 current physical dated 7/16/2020 did not indicate health maintenance needs. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | Individual #1's physical examination dated 7/16/2020 did have the health maintenance needs section completed by the physician. See page 5 of 5 on appendix e. |
10/12/2020
| Implemented |
| 6400.142(f) | Individual #1 record did not contain a dental hygiene plan. It listed him as independent but there was no plan. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | The interdisciplinary team will meet to document in writing that individual #1 has achieved dental hygiene independence, or will create a dental hygiene plan by the target date listed.
To prevent future occurrence program managers will be trained on regulation 6400.142(f) at an upcoming program manager meeting. this will be documented on the meeting minutes.
Person Responsible for carrying out and oversight: Program manager, Assist. Director and Director of Programs. |
11/11/2020
| Implemented |