| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Coppertone sunscreen was located on the main level bathroom on the vanity accessible to individuals. All other potentially poisonous substances were locked and inaccessible. The assessment for individual #1 said all poisonous materials are locked or inaccessible. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The Coppertone sunscreen was placed in a locked cabinet on the date of inspection
To prevent future occurrence program managers will be trained on regulation 6400.62(a). A 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 having poisonous materials unlocked or accessible will be corrected immediately by the person filling out the safety round form.
Person Responsible for carrying out and oversight: Program manager, Assist. Director and Director of Programs. |
11/11/2020
| Implemented |
| 6400.67(a) | The blinds in individual #1, bedroom were not on the window and damaged per statement of the agency. Agency stated a work order has been put in to replace blinds. No verification provided at time of inspection.
The outdoor seat located on the deck in the back yard was damaged. | Floors, walls, ceilings and other surfaces shall be in good repair. | A purchase order has been submitted for frosted windows for individual #1's bedroom (see Appendix F).
All program managers and other personnel responsible for checking physical site will be retrained on regulation 6400.67(a), and a 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 |
| 6400.144 | The Medication administration record (MAR) for individual #1, weight check was not logged on the first Thursday of each month per September 2020 physicians order. The supplemental vitals report did not obtain weight tracking for the first Thursday of September and was late the month of August (vitals report noted 8/13/2020) per orders. The health service prescribed by the physician was not being provided. The MAR was also left blank. | 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.
| The prescribed weight check for individual #1 was completed .
Actions taken to prevent future recurrence: all healthcare professionals responsible for documenting weight checks as prescribed by a physician in iMAR were retrained on this expectations (see appendix D). Additionally, all program managers who oversee homes with medication certified staff members will be trained on regulation 6400.144.
Person responsible: primary care nurse, healthcare coordinator, nurse manager, program manager, director of programs |
11/11/2020
| Implemented |
| 6400.32(i) | The thermostat located on the second floor hallway was locked and inaccessible to individuals in the home. The key to access Thermostat was not located on site. | An individual has the right of access to and security of the individual's possessions. | All homes will have an identified location where a key to the thermostat will be kept, so individuals will have access or will be able to gain access if a need for a temperature adjustment arises.
To prevent future occurrence program managers will be trained on regulation 6400.32(I).
Person Responsible for carrying out and oversight: Program manager, Assist. Director and Director of Programs. |
11/11/2020
| Implemented |