| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | Individual #1 is missing draw pull on her dresser.
Individual #2 is missing a draw pull on her dresser and she has a key lock, but no key.
Individual #3 is missing a draw pull on her dresser/no lock. | Floors, walls, ceilings and other surfaces shall be in good repair. | Both of these dressers have been replaced as of 6/23/23 |
06/23/2023
| Implemented |
| 6400.72(a) | The upstairs bathroom window does not have a screen.
There is no screen in the front living room window. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | new screens were placed in the windows 6/14/23. |
06/14/2023
| Implemented |
| 6400.77(b) | There is no antiseptic, assorted band aids, and tape found in the first aid kit. | 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, band aids and tape were purchased and placed in the first aid kit on 6/8/2023 |
06/08/2023
| Implemented |
| 6400.24 | Under the 1970 Controlled Substances Act, all class c medications must be double locked and counted at each administration of the medication:
The Klonopin (0.5 mg 1 tab at 8am had no second staff initialed for the count from 6/1-6/7/2023).
The Klonopin medication was not kept doubled locked.
The Klonopin medication count is off for the 8pm on 6/6/2023, the count was noted on the MAR as 23 pills, however the blister pack has 24 pills. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | this was corrected on 6/8/2023. The controlled substances are now in locked boxes inside a locked closet. |
06/08/2023
| Implemented |
| 6400.165(b) | Individual #1's PRN Acetaminophen was not on site but listed on the MAR.
Individual #1's Milk of Magnesia was not on site but listed on the MAR. | A prescription order shall be kept current. | The PRN medication Acetaminophen and Milk of Magnesia are in the home. They were ordered and delivered 6/8/2023. |
06/08/2023
| Implemented |
| 6400.165(c) | Individual #1's Depakote DR 125 mg 4 caps at 8a/8p, the bag had one pill laying at the bottom of the bag. | A prescription medication shall be administered as prescribed. | JEVS Associate Director called the pharmacy and had one Depakote pill delivered to the home to replace the one that had fallen out of the blister pack. |
06/08/2023
| Implemented |