| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.63(a) | The water temperature in the kitchen sink was 127.7 degrees F. | 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 individual living in this home has an assessment where it is documented she can regulate water temperatures independently. Additionally, this individual does not have access any of the heat sources as described in the cited regulation of 6400.63a. Please note that the water temperature in the individual's bathtub was, and continues to be, under the regulatory requirement of 120 degrees. |
01/16/2023
| Implemented |
| 6400.64(a) | There is an odor consistent with urine in Individual #1s bedroom. *Recommend a thorough cleaning*
There is a dark substance consistent with mildew or mold in the dishwasher and deep freezer located in the kitchen of the home. | Clean and sanitary conditions shall be maintained in the home. | As this individual does have an issue with incontinence, the individuals¿ mattress was replaced and covered with a liner to prevent any incontinence issues from seeping into the mattress which may be contributing to the odor in individual 1's bedroom.
The deep freezer was no longer in use in the individual¿s apartment, and as such, the Service Director, along with the staff, removed the item from the apartment. Additionally, the dishwasher which was not actively being used by the individual, was cleaned by staff to remove the appearance of mold. |
12/15/2022
| Implemented |
| 6400.71 | There are no emergency contact lists by the phones in the home. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| Per guidance provided using the ODP Regulatory Compliance Guide (pg. 60), and based on feedback from 2020 licensing visit, 911 stickers were present on all of the phones located at this location. However, emergency contact numbers were posted near each of the phones at this location for this individual on 11/21/22 (ATTACHMENT #14). |
11/21/2022
| Implemented |
| 6400.112(d) | The asleep drill on 9/9/22 took 2:37 minutes at 4:45am, There was not another drill conducted that month and no letter from the fire expert was found in the record that stated that the time of 2:37 seconds was sufficient and safe for the individual to evacuate. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | A repeat overnight drill was completed on 11/23/22 to verify that the individual in this home was able to evacuate under the 2 minute, 30 second requirement (ATTACHMENT #15 ). This individual has consistently evacuated under the required timeframe and this repeat drill demonstrated the same results. Additionally, an overnight drill was completed in December as scheduled and this individual evacuated without issue under the 2 minute, 30 second requirement (ATTACHMENT #16 ). |
11/23/2022
| Implemented |
| 6400.142(e) | Individual #1's 4/4/22 dental visit calls for a follow-up with periodontics due to advanced periodontitis; agency records do not contain documentation showing the follow-up was scheduled or completed. | Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed. | The delay in scheduling this appointment was an oversight of the staff supporting her at the time. However, an appointment has been scheduled for 3/30/23 at 10:00AM with Temple Dental Clinic. This was the first available appointment at the clinic that can meet individual 1's dental need. |
03/30/2023
| Implemented |
| 6400.151(a) | physical for Staff 1 was completed 10.22.20 and next physical was completed 11.5.22 physicals need to be completed every 2 years. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Staff 1¿s physical is now in compliance as of 11/5/22. |
01/19/2023
| Implemented |