| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(a) | Fire Drills for the home were not held during the months of April and May of 2021. | An unannounced fire drill shall be held at least once a month. | The Fire Drill for this location was run on July 21. There was no drill run in April or May and no way to recreate this for the cited months. Starting in July 2021, Unnanounced Fire drills are held monthly and tracked on the fire drill check list by location, by the Director of Residential. |
07/21/2021
| Implemented |
| 6400.144 | The MAR/medication review revealed that staff were unable to manipulate the electronic system to the extent that licensing staff could observe that all medications were given at the prescribed intervals.
Individual #1 is diabetic and there is no sliding scale or instructions for when glucose readings are too high or low. | 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.
| I have no record of staff training that occurred in July regarding logging into Emar for the cited location, corrective actions for all homes noted here. Regarding the sliding scale, on 7/16/21 a fax was sent to pcp for scale asking for follow up. On 7/19/21, instructions were developed after discussing with PCP/Endocrine for parameters for insulin usage. This was posted in the home and staff were trained on it. |
07/16/2021
| Implemented |
| 6400.163(f) | Individual #1's diabetic medications were kept unlocked in the refrigerator. | Prescription medications stored in a refrigerator shall be kept in an area or container that is locked. | On July 16, 2021, lockbox was provided and the individual's diabetic medications were locked |
07/16/2021
| Implemented |
| 6400.169(b)(2) | The staff working with individual #1 in the home are not trained in diabetic care. Individual #1 is diabetic. | A staff person may administer insulin injections following successful completion of both: A Department-approved diabetes patient education program within the past 12 months. | Staff were trained in diabetic care on 7/26/21. |
07/26/2021
| Implemented |