Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.67(a) | Door leading to the back door hits the awning which is drooping down a bit causing resistance on the door when opened. Needs to be adjusted to ensure it is fully unobstructed | Floors, walls, ceilings and other surfaces shall be in good repair. | The Maintenance Director adjusted the door immediately after inspection on 7/15/22. The door now opens unobstructed and provides safe egress. |
07/15/2022
| Implemented |
6400.112(e) | The sleep drills were not completed every 6 months. There were no sleep drills conducted in the 6 month period between 1/1/2022 through 6/30/2022. A sleep drill was recently conducted in July 2022 and previously completed in December 2021. | A fire drill shall be held during sleeping hours at least every 6 months. | A sleep drill was completed in July 2022 as noted. The next drill will be completed January 2023 to get on a 6 month schedule that ensures compliance. Additionally, Team Leads and Lead workers were trained on 6400.112(e) |
07/01/2022
| Implemented |
6400.144 | The following two PRN medications prescribed to individual #1 were not present at site at time of inspection:
Cetitizine Tab 10mg -- 1 tablet by mouth as needed each year from July 1 -- February 28
Hydrocort Cream 1% - Apply to affected area topically twice daily as needed for eczema rash | 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 two PRN Medications were ordered by the Nurse and placed immediately in the medication box on 7/14/22. A medication audit was completed by the Nurse to ensure that all prescribed medications were present. |
07/14/2022
| Implemented |
6400.34(b) | There is no updated copy of signed individual rights for individual #1. Most recent copy is from July 9, 2021. | The home shall keep a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights. | The Program Specialist discussed the individual rights statement and obtained a signature from individual #1 on 8/1/22. The statement is now filed in the individual's chart at the Peaceful Living office as well as in the individual's home in order to meet the standard in 6400.34(b). |
08/01/2022
| Implemented |