| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | There was no operable light in the pantry closet. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Provider¿s maintenance team has repaired the light in the pantry closet on 12-20-22. |
12/20/2022
| Implemented |
| 6400.111(c) | There was no fire extinguisher located in the kitchen at time of inspection. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | Provider maintenance team installed a new fire extinguisher in the kitchen on 1-26-23. |
01/26/2023
| Implemented |
| 6400.112(c) | The fire drill form dated 7/19/22 & 8/24/22 does not indicate whether smoke detectors or fire alarm was operable. | 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. | A retraining on fire drill form has been conducted by the Program specialist and the CEO to ensure all information are accurately captured on the form. |
01/10/2023
| Implemented |
| 6400.113(a) | Individual #1's two most recent fire safety trainings were greater than a year apart, dated 5/12/22 and 1/15/21. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | Provider Program Specialist will review the fire safety training quarterly to ensure that training is completed before the annual due date. |
12/22/2022
| Implemented |
| 6400.141(a) | Individual #1 has not had physicals annually. Their two most recent physicals were dated 4/23/19 and 4/27/22. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Provider Program specialist ensured all appointments have been scheduled for the current year. Individual # 1 annual physical date is set for 02-22-23
Correction status is ongoing.
Target date 2-22-23 |
02/22/2023
| Implemented |
| 6400.141(c)(3) | Individual #1's 4/27/22 physical does not contain a record of immunizations. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Provider Program specialist has requested individual 1 immunization record to be provided during next visit of 02-22-23
Correction status is ongoing
Target date is 02-22-23. |
02/22/2023
| Implemented |
| 6400.141(c)(7) | Individual #1 does not have a current OB/GYN exam with PAP test on record. Their last OB/GYN visit was 10/20/20. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Provider Program specialist ensured all appointments have been scheduled for the current year.
Individual #1 OB-Gyn exam with PAP test date is set for 02-22-23.
Target date is 02-22-23 |
02/22/2023
| Implemented |
| 6400.143(a) | Individual #1 did not see a dentist in 2021. Agency staff indicated they refused the visit; refusal documentation was requested but not provided. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | Provider Program specialist ensured all appointments have been scheduled for the current year. Individual 1 dental appointment is scheduled for 04-19-23.
Correction status is ongoing
Target date is 04-19-23 |
04/19/2023
| Implemented |
| 6400.144 | There was Children's Motrin 100mg that was found in the refrigerator where the individual has access. The medication had no prescription label. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| The citated material was removed from the house on 12-20-22. |
12/20/2022
| Implemented |
| 6400.165(g) | Individual #1 has not had quarterly medication reviews. Their last medication review was in February 2020. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | A medical visit plan form has been implemented by provider Program specialist to ensure all psychotropic visits are properly documented by individual #1 doctor. An appointment has been scheduled with individual #1 psychiatrist for 03-09-23
Correction status is ongoing.
Target date is 03-09-23 |
03/09/2023
| Implemented |
| 6400.213(1)(i) | Individual #1's photo is undated in their record. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Program Specialist updated individual# 1 face sheet including a most recent picture taken 05-22-19. |
12/22/2022
| Implemented |