| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | At the time of virtual inspection, there was no light in the stairwell leading down to the basement. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Sunset installed a new light at the top of the steps. Sunset CEO, or whom he designates this responsibility to, will be conducting monthly house checks using the Regulatory Compliance Guide to ensure that all homes should have adequate lighting to assure safety and avoid accidental falls. |
03/02/2021
| Implemented |
| 6400.144 | Health services are to be arranged and provided for the individual by the provider. On 12/16/2020 and 12/17/2020 staff notated on the Medication Administration Record (MAR) that medication "alprazolam" was not given due to the "pharmacy has not delivered yet". This happened again on 12/18/2020 for medications, "Divalproex" and "Chlorpromax". This occurred again on January 1st, 2021 with medication "Alprazolam" on January 8th , 9th , and 10th with medication "Lactulose", and on January 15th with medication "Guanfacine".
The provider failed to provide health services to the individual by not assuring that medications are being refilled in a timely manner, which resulted in the individual not receiving the correct medication at the prescribed times. | 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.
| Sunset updated our policies and procedures on how to reorder medications in a timely manner and also what to do when staff run out of a medication. Sunset will retrain all staff on these new changes before April 15, 2021. |
03/02/2021
| Implemented |
| 6400.216(a) | At the time of the virtual inspection of Individual #1's home, records with identifying information was located on an unlocked, open bookshelf, in an office that does not have the capability to be locked. | An individual's records shall be kept locked when unattended.
| Sunset purchased a file cabinet with a lock to ensure that the individual's records are locked up when unattended. Sunset, in the future, will install a door on the office to allow easy access to program files. In the mean time, staff will lock program files in file cabinet until door is installed. |
03/02/2021
| Implemented |
| 6400.34(a) | The individual rights form signed by the individual does not contain all of the rights information afforded to the individual according to regulations 6400.32a-v. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Sunset's CEO updated our individual admission packet to include all items in 6400.34. |
03/02/2021
| Implemented |
| 6400.166(d) | Individual #1's medications were not administered as prescribed on 12/16/2020, 12/17/2020, 12/18/2020, 1/1/2021, 1/8/2021, 1/9/2021, 1/10/2021, and 1/15/021 due to the medications not being present in the home on the day and time it was to be administered. The provider did not ensure that the medication refills were picked up by a staff member in person at the pharmacy when the delivery did not arrive on time. | The directions of the prescriber shall be followed. | Sunset updated our policies and procedures on how to reorder medications in a timely manner and also what to do when staff run out of a medication. Sunset will retrain all staff on these new changes before April 15, 2021. |
03/02/2021
| Implemented |