| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | On 7/18/13 at 2:30pm, a 20oz bottle fo Pine Glo disinfective was unlocked in a basement cabinet. The warning lable states "seek medical if ingested." | (a) Poisonous materials shall be kept locked or made inaccessible to individuals.
| This violation resulted from the direct service worker (DSW)not following behind the individual to ensure that the poisonous material was locked immediately after the individual made use of the detergent for laundry.
This individual is high functioning and has authorized 10 hrs of unsupervised time in her home, as well as unsupervised time in the community. She has been functionally assessed to be aware of poisonous substances. At the time of inspection, the individual was washing her clothing. However, the poisonous material was placed in the cabinet and locked immediately.
It is now a policy that the DSW must ensure that after opening the cabinet for the individual to use any item for laundry/cleaning, the DSW must also ensure that they lock the cabinet immediately afterwards. |
07/19/2013
| Implemented |
| 6400.66 | On 7/18/13 at 2:15pm, there was no light in the basement stairway.
On 7/18/13 at 2:10pm, there was no light in the second floor bathroom. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| This violation resulted from the inability of the Residential program to follow through the regulations as it relates to lightening in and around the home.
Light bulbs were replaced immediately and effective Lightening has been restored in the basement stairway and second floor bathroom.
Staff are now required to check the site during every shift to ensure that all the lights are working and that there is effective lightening in the home. Homes shall be provided extra light bulbs so that defective ones can be changed on the spot. However, greater lightening issues shall be referred to maintenance to rectify immediately. |
07/24/2013
| Implemented |
| 6400.76(a) | On 7/18/13 at 2:30 pm, there was a half and inch of lint in the dryer's lint trap. | (a) Furniture and equipment shall be nonhazardous, clean and sturdy.
| This violation resulted from the inability of staff to adhere to the instructions regarding the use of dryers in the home.
The particular dryer in question had its lint cleaned out immediately on 07/18/2013.
Site supervisors will in-service all staff (DSW) on proper home dryer instructions for the removal of lint. A checklist has also been developed for staff to complete after every dryer cycle. Signs will also be posted at all sites as a reminder for staff to remove lint from dryer after every usage. |
08/31/2013
| Implemented |
| 6400.101 | The rear basement door exit was obstructed with a locked door that could not be opened. The door has an "EXIT" sign posted on it. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| This violation resulted from the Residential program's inability to adhere to the regulations on unobstructed egress.
The rear basement door exit (leading into a storage area), which is the second exit in the basement had its lock removed immediately and has remained accessible.
Going forward, all exits on each floor in the homes, regardless of the number of exits shall remain unobstructed. |
07/20/2013
| Implemented |
| 6400.112(c) | The home's fire drill records for the following dates only listed the minutes taken to evacuate and not the seconds:
7/19/13 2 minutes
6/21/13 2 minutes
5/10/13 2 minutes
4/10/13 2 minutes
3/14/13 2 minutes
2/02/13 2:00 seconds | (c) A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative.
| This violation resulted from the inability of staff in this home to appropriately complete the fire drill record form.
All staff will be re-in serviced on accurate recording on fire drills of the date, time, amount of time for evacuation, exit route used, problems encountered, and whether the fire alarm or smoke detector was operative. Special emphasis shall be placed, on appropriately recording the amount of time for evacuation for members of staff in this home. |
10/31/2013
| Implemented |
| 6400.164(c) | Individual #1's, who self medicates, Medication Administration Record did not list the name of the prescribing physician that prescribed Calcium 600mg and Hetz 25mg. | (c) A list of prescription medications, the prescribed dosage and the name of the prescribing physician shall be kept for each individual who self-administers medication.
| This violation resulted from the inability of the Residential department to follow through on the regulation as it relates to an Individual who self-medicates and the record of the medication and prescribing physician.
This violation was corrected on 07/18/2013. All supervisors have been trained (07/19/2013)and appropriately instructed on the guidelines and procedures of identifying medications in the MAR that is not prescribed by the PCP;and as such those medications must have the prescribing physician's name alongside the medication.
Going forward monthly, all supervisors shall review the MARS on receipt from the pharmacies, to check for completeness and accuracy of all required information. The Director of Residential Services shall reconfirm the completeness and accuracy before the MARS go out to the homes. |
07/19/2013
| Implemented |