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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.63(a) | On 11/15/2023 at 12:23 PM, the hot water temperature at the bathroom sink measured 126.3 Degrees Fahrenheit. On 11/15/2023 at 12:25 PM, the hot water temperature at the kitchen sink measured 127.7 Degrees Fahrenheit. | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | The hot water tank was turned down by maintenance personnel on 11/15/23. A recheck of the water temperature at the kitchen sink, bathroom sink and shower was done 2 hours later. The temperature measured 118.3 Degrees Fahrenheit at the kitchen sink, 116.7 Degrees Fahrenheit at the bathroom sink, and 117.2 Degrees Fahrenheit at the shower. The temperature check and adjustment was documented on the water temperature check form already utilized by maintenance personnel monthly. |
11/15/2023
| Implemented |
| 6400.207(5)(III) | On 11/15/2023 at 12:45 PM, Individual #1's bed contained partial bedrails that restricted the movement or function of their body. | A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Protection from injury during a seizure or other medical condition, if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement. | The partial bedrails were removed from individual #1's bed on 11/15/23 by maintenance personnel. Awake overnight staff make periodic checks throughout the night when the individual, who is diagnosed with a seizure disorder, is sleeping to ensure the individual is maintaining a safe sleeping position. An appointment has been made with individual #1's PCP to discuss whether or not there is a medical need to utilize partial bedrails for balance/support to achieve functional body position or protection from from injury during a seizure. This appointment is scheduled for 12/20/23. |
11/15/2023
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.111(f) | The most recent date of inspection on the fire extinguishers in the kitchen and garage of home was 10/2015. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | On 11-22-16 the fire extinguishers were replaced by maintenance staff with currently inspected fire extinguishers. A picture was taken and given to the inspector that same day. On 12-5-16, the staff were retrained by the Program Specialist on the agency's fire safety procedures, including monthly checks of all fire extinguishers. To ensure the fire extinguishers at all sites are currently inspected, the Program Specialist will complete quarterly checks and will keep a record of these checks, in addition to the monthly checks already completed by staff. The Program Specialist will contact a fire safety expert to inspect any fire extinguisher needing inspected prior to the expiration date. |
12/09/2016
| Implemented |
| 6400.162(a) | Ammonium Lactate Cream 12% and Clotrimazole Cream USP 1% prescribed for Individual #1 did not have a pharmaceutical label on the containers. | The original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. | On 11-23-16, staff took the two medications to the pharmacy and had them labeled with the proper pharmaceutical label. On 12-5-16, the staff were retrained by the agency¿s medication administration trainer on the 15 steps of correct administration of medication. These steps include doing 4 checks in which staff are to match the pharmaceutical label of each medication to the MAR during the administration process. When new medications arrive to each site, staff will check the packaging to ensure the medication has been properly labeled. If a medication does not have a label, the staff will take it to the pharmacy to be labeled. Documentation of this check will then be marked on the staff changeover and turned into the Program Specialist monthly. The agency nurse will also provide monthly checks of the medications at each site to ensure they have been properly labeled. The nurse will document these checks and any problems associated with any medication and turn the documentation into the Program Specialist for review. |
12/09/2016
| Implemented |
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