| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | Water temperature was 125.6°F in the bathroom, | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The water temperature was adjusted to below 120 degrees on 7/13/22 by the Maintenance Director. All staff were trained on 6400.68 (b) and a water check form was created to ensure proper tracking of water temperatures. |
07/13/2022
| Implemented |
| 6400.82(e) | No non-slip mat was present in the bathroom | Bathtubs and showers shall have a nonslip surface or mat. | A Non- slip bath mat was placed on 7/15/22. All current staff in the home were trained in 6400.82 on 8.2.22. Additionally, bathroom safety training was added to the in house training packet so that all new staff are trained immediately. |
07/15/2022
| Implemented |
| 6400.104 | The fire department letter was not updated when the capacity of the home changed in April 2022. A recent letter has since been mailed on 6/29/2022 to the local fire department . | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| The Program specialist will immediately update the Fire Department when any changes are made. The admission check list has been revised to include notification to fire department when changes are made in the home. The Program specialist and Team Leads have been trained on 6400.104 on 8/2/22 |
07/14/2022
| Implemented |
| 6400.144 | The PRN Heat Wrap -- Prescribed to individual #1 was not present in the medication box of the individual. | 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 heat wrap was ordered and placed in the medication box on 7/15/22. A medication audit was completed to ensure all prescribed medications were present in the home on 7/15/22. |
07/15/2022
| Implemented |
| 6400.163(g) | The following medication was present in the medication box of individual #1 but was no longer an active medication:
Cyclobenzapr tab 10 MG -- 1 tablet as needed for muscle spasms | Prescription medications shall be stored in an organized manner under proper conditions of sanitation, temperature, moisture and light and in accordance with the manufacturer's instructions. | The medication was removed immediately on 7/13/22. All medications were checked to ensure no medications that did not belong there were present anymore. Staff in the home were trained on 6400.163(g). |
07/13/2022
| Implemented |
| 6400.165(b) | PRN Sore Throat Spray prescribed to individual #1 and present in the medication box had expired in May of 2022 | A prescription order shall be kept current. | The Throat Spray was removed immediately on 7/13/22. Utilizing the medication audit tool, A medication audit was completed by the Nurse for the individual as well as all individuals living in the home to ensure there were no expired medication. |
07/13/2022
| Implemented |
| 6400.165(c) | Individual #1 is prescribed Calcium antacid chew -- 500 MG to be taken at 8:00am and 4:00pm
Per the MAR this medication was administered at the following times:
7/3/22 4pm dose given at 8:34pm
7/11/22 4pm dose given at 8:03pm
7/12/22 8am dose given at 7:38pm | A prescription medication shall be administered as prescribed. | All staff in the home reviewed Peaceful Living's Medication Adminstration Policy and signed a training sheetc7/15/22. The policy specifies that there is a 1 hour window in either direction of a medication time that a staff person can give a medication, and that all meds need to be given within that window. |
07/15/2022
| Implemented |
| 6400.165(g) | Psychotropic medication reviews have not been completed every 90 days. The only complete psych med review was completed in June 2022. In Sept 2021 and March 2022, there are only notes that Individual #1 saw a therapist or a psychiatrist, but there are no details surrounding her visit. Each visit should have documentation of the reason for prescribing the medication, the need to continue the medication, and the necessary dosage. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | On 7/15/22 The Nurse and Team Lead were retrained on the appropriate psych med review form that is to be used during a 90 day review. The form specifies the above criteria noted in 6400.165(g). |
07/15/2022
| Implemented |