Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.67(a) | The dressers located in Individual #4 and Individual #5's bedrooms were not in good repair. Both were missing knobs which didn't allow the individual to open their drawers. | Floors, walls, ceilings and other surfaces shall be in good repair. | The knobs were replaced on the dresser in Individual #4 and Individual #5 bedroom on 8/12/2021. Please see attached copy of dresser with knobs attached labeled Item #10. |
08/12/2021
| Implemented |
6400.76(a) | Furniture chairs in the dining room were damaged. | Furniture and equipment shall be nonhazardous, clean and sturdy. | New Dining room furniture was purchased on 9/24/2021. Please find attached a copy of the receipt for the furniture labeled Item #11 |
09/24/2021
| Implemented |
6400.77(b) | The first aid kit did not contain tweezers or assortment bandages at time of inspection. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | Tweezers and assorted bandages were placed in the first aid kit on 7/23/2021. please see attached picture of first aid kit with tweezers and assorted bandages. |
07/23/2021
| Implemented |
6400.112(e) | A sleeping fire drill was not held every 6 months for Briarwood. | A fire drill shall be held during sleeping hours at least every 6 months. | A sleeping fire drill was done on 8/8/2021, please see attached copy of sleeping fire drill labeled Item 13 |
09/23/2021
| Implemented |
6400.141(c)(6) | TB tests for Individual #4 exceeded two year time limit. Previous TB test was 7/2018, most recent one was on 6/15/21, which is almost three years. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | TB Test for Individual #4 was done on 6/15/21. The next test is due 6/15/2023.
The Royer Greave Nurse will administer and track all TB test. |
09/23/2021
| Implemented |
6400.181(d) | Program specialist did not sign and date the assessment for Individual #4. | The program specialist shall sign and date the assessment. | The program specialist has signed and dated Individual #4 assessment. Please see attached copy of signed assessment labeled Item #16 |
09/23/2021
| Implemented |
6400.165(b) | Medication Loratadine Tab 10mg for Individual #4, was in his med box expired on 3/03/21 at time of inspection. Agency refilled the prescription for this medication. | A prescription order shall be kept current. | The medication Loratadine Tab 10mg was refilled on 7/21/2021. |
09/23/2021
| Implemented |
6400.169(d) | Medication administration training did not contain a feedback date where it's indicated Staff #4 passed the training. | A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed. | Staff #4 feedback date was documented on her training form. Please see attached copy of staff #4 training paperwork labeled #17 |
09/23/2021
| Implemented |