Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.63(a) | REPEAT from 8/22/23 unannounced inspection: At the time of the inspection, the water temperature in the bathroom sink measured at 122.3. | 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 water temperature was turned down on the water heater at the time of inspection. |
11/23/2023
| Implemented |
6400.81(k)(6) | At the time of the inspection, Individual #1 did not have a mirror available in their bedroom. | In bedrooms, each individual shall have the following: A mirror. | A mirror has been installed in Individual#1's bedroom.
Attachment 32 |
11/23/2023
| Implemented |
6400.104 | REPEAT from 8/22/23 unannounced inspection: The most recent letter sent to the fire department on 4/1/23 does not document the exact location of each individual's bedroom. | 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.
| An updated letter has been sent to the local Fire Department which includes 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.
Attachment 33 |
11/23/2023
| Implemented |
6400.112(f) | From June 2023 through the present Individual #2 only exited out of the home during fire drills from the exit in their bedroom. | Alternate exit routes shall be used during fire drills. | A Fire Drill was conducted on November 16, 2023 where Individual #2 exited out the front door of the home.
Attachment 34 |
11/23/2023
| Implemented |
6400.112(g) | The fire drills completed on 7/29/23, 8/22/23, and 10/5/23 do not indicate if the drills occurred in the am or pm. | Fire drills shall be held on different days of the week and at different times of the day and night. | The electronic Fire Drill form has been reformatted to include the name of the person conducting the drill, the date of the drill being completed, a separate entry for AM or PM and an entry field for the designated meeting place. All entry fields are required for successful submission of the form.
Each home has an assigned designated meeting place which is identified in the Fire Safety Manual at the home.
Attachment 35 |
11/23/2023
| Implemented |
6400.112(h) | All of the individuals did not meet at the meeting place during the fire drill conducted on 7/29/23, because staff felt the meeting place "was too far" and they met at a different meeting place. No designated meeting place was identified on the drills. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | The electronic Fire Drill form has been reformatted to include the name of the person conducting the drill, the date of the drill being completed, a separate entry for AM or PM and an entry field for the designated meeting place. All entry fields are required for successful submission of the form.
Each home has an assigned designated meeting place which is identified in the Fire Safety Manual at the home.
Attachments 34, 36 |
11/23/2023
| Implemented |
6400.141(c)(13) | Individual #1's current physical completed 2/20/23 says no "drug allergies." However, Individual #1 is allergic to Depakote. | The physical examination shall include: Allergies or contraindicated medications. | Individual #1's physical was updated to include the allergy to Depakote consistent with the documentation presented at the appointment within the life time medical history.
The physical form has been returned to the physician for signature.
Attachment 37 |
11/23/2023
| Implemented |
6400.141(c)(14) | Individual #1's current physical completed 2/20/23 did not address the information pertinent to diagnose/treat in case of an emergency. This section was blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Individual #1's physical was updated to include Medical information pertinent to diagnosis and treatment in case of an emergency.
The physical form has been returned to the physician for signature.
Attachment 38 |
11/23/2023
| Implemented |
6400.144 | Repeat from 3/3/23 and 8/22/23 unannounced inspections: Individual #1 has a bowel protocol that their bowel movements are to be tracked daily and they are to receive Miralax if they have no bowel movement in three days. At the time of the inspection, there was no Miralax available in the home. From 6/1/23 to the present, there were a total of 13 days in which it was not tracked whether Individual #1 had a bowel movement. | 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.
| Staff have been reinstructed regarding the proper documentation of bowel charting as well as the importance of maintaining an accurate record to ensure the health of the individuals is properly safeguarded.
Attachment 14 |
11/23/2023
| Implemented |
6400.46(b) | Staff #1's 7/13/23 annual fire safety training received was conducted via an electronic CDC fire safety video. There are no records that the fire safety training was specific to the home, to include home specific fire safety training on evacuation procedures, responsibilities, designated meeting place, use of fire extinguishers, etc. The home did not have the specific meeting place for the home identified on any of their home specific plans and procedures, to be able to provide that with fire safety training. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | The Training record has been amended with documentation of the content of topics specific to their home. Including:
General Fire Safety
Evacuation Procedures
Responsibilities during fire drills
The designated meeting place outside of the building or within the fire safe area in the event of an actual fire.
Smoking Safety Procedures.
Attachment 39 |
11/23/2023
| Implemented |
6400.166(a)(2) | The November MAR's for Individual #1 had contradictory information regarding who the prescriber is for the following medications: Simvastatin, Aspirin, Loratadine, Clorazepate, and Levetiracetam. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | The MAR has been corrected to reflect the current prescirber for each medication.
Attachment 41 |
11/23/2023
| Implemented |
6400.166(a)(4) | At the time of the inspection the following medications were available in the home for Individual #1 and none of the required information was documented on the MAR: Hemorrhoidal Ointment, Tylenol, Imodium AD, and Medicated Body Powder. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | These OTC medications were obtained by Individaul#1's mother and brought to the home. Individual#1's assessment has been updated to include their ability to safely self-administer OTC medications and has been forwarded to the Supports Coordinator with a request to update the ISP accordingly.
Attachment 42 |
11/23/2023
| Implemented |
6400.166(a)(7) | Individual #1 is prescribed Acetaminophen 325 MG as needed. At the time of the inspection, 500mg of Acetaminophen was available in the home. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | The Acetaminophen 325 MG has been located in the home and is available for administration.
Attachment 43 |
11/23/2023
| Implemented |
6400.167(a)(1) | Repeat from 3/3/23 and 8/22/23 unannounced inspections: Individual #1 has a bowel protocol that they are to receive Miralax if they go three days with no bowel movement, and every day subsequently until they have a bowel movement. Individual #1 went with no bowel movement at least three days a total of three times. They were to receive a dose of Miralax on the following dates: 7/31/23, 8/1/23, 8/13/23, 8/14/23, 8/24/23, and 8/25/23. | Medication errors include the following: Failure to administer a medication. | Staff have been reinstructed regarding the proper documentation of bowel charting as well as the importance of maintaining an accurate record to ensure the health of the individuals is properly safeguarded.
Attachment 14 |
11/23/2023
| Implemented |
6400.213(1)(i) | Individual #1's most recent photo was taken on 3/30/21. | 213(1)vi-Each individual's record must include the following information: Personal information, including: Current, Dated Photo. | Individual#1's photo has been updated to be current.
Attachment 45 |
11/23/2023
| Implemented |