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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.32(f) | Individual #1's, date of admission 8/06/2022, medications are being administered by placing all tablets in a bowl and mixing the medications with applesauce or yogurt. Staff are then feeding the applicable medication to Individual #1 with a spoon. This takes away Individual #1's right to refuse the medication as they are unaware of what medication they are being given. | An individual has the right to refuse to participate in activities and services. | On 8/9/2023 the Primary Care Physician was contacted, the physician sent an order to the pharmacy stating ; Please administer patient's medications orally mixed in applesauce, yogurt or pudding.
on 08/10/2023 new labels reflecting the order were sent from the pharmacy and applied to the blister packs of medications. The electronic MARs were also changed to reflect the Physician's order also sent to the office of HNA.
On 08/11/2023 the House Managers were retrained on the Individual's Rights and the process of changing the delivery method of medication needed for health and safety of the individual. |
08/28/2023
| Implemented |
| 6400.165(c) | Individual #1 is prescribed the following medications: Levothyroxine 50 MCG Tablet - Take 1 tablet by mouth once daily for hypothyroidism, Famotidine 20 MG Tablet - Take 1 tablet by mouth daily at 8 AM for acid regurgitation, and Melatonin 3 MG Tablet - Take 1 tablet by mouth daily at bedtime 8 PM for sleep. All of Individual #1's medications are being administered by placing the tablets in a bowl and mixing the medications with applesauce or yogurt. Staff are then feeding the applicable medication to Individual #1 with a spoon. | A prescription medication shall be administered as prescribed. | On 8/9/2023 the Primary Care Physician was contacted, the physician sent an order to the pharmacy stating ; Please administer patient's medications orally mixed in applesauce, yogurt or pudding.
on 08/10/2023 new labels reflecting the order were sent from the pharmacy and applied to the blister packs of medications. The electronic MARs were also changed to reflect the Physician's order also sent to the office of HNA. |
08/28/2023
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | On 8/3/22, the bathroom in the basement did not have operable lighting. On 8/3/22, the garage area did not have operable lighting, there was no light bulb in the light fixture. On 8/3/22, there was no operable lighting outside of the basement exit. When the light switch was utilized, the lighting fixture did not turn on. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Lighting is operable in the basement bathroom, garage as well as the light outside the basement door. All light bulbs have been replaced. [Training form, dated 9/20/22, on the requirements related to proper lighting was received on 9/23/22 and reviewed 9/28/22. The Monthly Site Audit form template was received on 9/23/22 and reviewed 9/28/22. Verification of operable lighting via pictures was received on 9/23/22 and reviewed 9/28/22. DPOC by HDKP, HSLS, on 9/28/22]. |
09/30/2022
| Implemented |
| 6400.82(f) | On 8/3/22, the bathroom located in the basement did not have soap available. Additionally, the basement bathroom did not have individual clean paper or cloth towels available. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Soap and paper towels were put into the basement bathroom. [Training document, dated 9/20/22, on required components of all bathrooms received on 9/23/22 and reviewed on 9/28/22. DPOC by HDKP, HSLS, on 9/28/22]. |
09/30/2022
| Implemented |
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