| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.68(b) | The water temperature measured 132.2 degrees Fahrenheit in the upstairs bathroom at the time of the inspection. | Hot water temperatures in bathtubs and showers that are accessible to individuals may not exceed 120°F. | The Provider turned down the temperature setting immediately upon departure from the inspector. The hot water setting was already set at 115 but it was turned down lower than that. The providers were instructed to check the temperature of the water for a period of 7 consecutive days to ensure that the water did not exceed 120 degrees. The providers noted that the water stayed below 120 degrees for 7 consecutive days and continue to monitor once monthly. |
04/28/2022
| Implemented |
| 6500.109(f) | Fire drills are held every six months in the home. The fire drills held on 10/22/2021 and 4/03/2022 both utilized the exit door located near the Individual's bedroom. Alternate exits were not used. | Alternate exit routes shall be used during fire drills. | The provider was retrained on fire safety and alternate exits. The provider will ensure that alternate exits are used every 6 months during fire drills. |
04/25/2022
| Implemented |
| 6500.132(a) | Individual #1 was admitted to the current home on 10/23/2021 and is unable to self-administer medications. Staff #1 has been administering medications to Individual #1 since their date of admission but did not receive Medication Administration Training until 4/09/2022. Staff #1 was not qualified to administer medications from 10/23/2021 to 4/09/2022. | Staff persons or others who are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication. | The provider staff was retrained on Medication Administration and what is required to become a medication administrator. |
04/09/2022
| Implemented |
| 6500.133(h) | Individual #1's pro re nata (PRN) medication Diazepam expired 11/25/2020 but was still stored with the Individual's current medications and had not been disposed of properly. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | The expiration date printed on the Diazapam bottle was not expired but the label on the medication case was expired. New labels were printed from the pharmacy for the label on the storage container to match the Diazapam expiration date. The provider will ensure that the date on the Diazapam is the same as the date on the storage container. When the PRN is close to expiration the Provider will request a refill and a new label for the container as well. |
04/28/2022
| Implemented |