| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.111(a) | The only fire extinguisher located on the basement level of the home had a 1A rating. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | A plan has been set in place that monthly, a review of all fire extinguishers will occur. At the time of the fire drill, the information regarding the expiration of the fire extinguisher will be done by the site supervisor. Program Specialist will ensure that the monthly review of fire drills captures this information.
To maintain compliance two new Fire Extinguishers with a 2-A rating have been added to the residential site to maintain compliance with the regulation. |
08/16/2021
| Implemented |
| 6400.111(c) | The only fire extinguisher located in the kitchen of the home had a 1A rating. | 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). | A plan has been set in place that monthly, a review of all fire extinguishers will occur. At the time of the fire drill, the information regarding the expiration of the fire extinguisher will be done by the site supervisor. Program Specialist will ensure that the monthly review of fire drills captures this information. |
08/16/2021
| Implemented |
| 6400.166(a)(11) | Individual #1's August 2021 medication administration record did not include: Diagnosis or purpose for any of the medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Agency nurse received the updated medication cards for the participant from the agency contracted PDC Pharmacy on 8/16/21. A meeting was held via telephone with the pharmacy to adjust the error in missing purpose of medication info. The data was updated on the medication administration record. A review of all participants medication purpose was completed during the week of 8/16/2021. For August, the new medication cycle EMAR reflecting these changes with medication reasons is current. |
08/16/2021
| Implemented |