| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | At 10:55AM on 2/14/2023, there was a 32oz spray bottle of Lysol Power Bathroom Foamer under the sink in the bathroom in the basement of the home. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The Lysol cleaner was removed from under the sink and placed with the other cleaning products and poisonous materials, in a locked area that is inaccessible to the individuals.- 2/15/23 |
03/15/2023
| Implemented |
| 6400.72(b) | There is a temporary screen in Individual #1's bedroom window that does not securely fit the window. There is a temporary screen in Individual #2's bedroom window that does not securely fit the screen. There are two, three-inch by three-inch holes in the screen across from the stairs in the attic of the home. There is a four inch long tear in the screen on the left side of the attic in the home. | Screens, windows and doors shall be in good repair. | All screens that were cited were removed, measured, and replaced with new screens that securely fit the windows and are without blemish. Documentation of proof of purchase and installation have been retained.- 2/19/23 |
03/15/2023
| Implemented |
| 6400.74 | The five exterior steps on the side of the home do not have a nonskid surface. | Interior stairs and outside steps shall have a nonskid surface.
| The five exterior steps cited have been painted with a non skid surface paint. The name of the paint is HC Shark Grip Slip Resistant Additive. Photographs of the steps and proof of purchase have been retained for documentation. |
02/20/2023
| Implemented |
| 6400.77(c) | The first aid kit did not include a first aid manual. | A first aid manual shall be kept with the first aid kit. | A first aid manual has been added to the cited first aid kit. 2/20/23 |
03/15/2023
| Implemented |
| 6400.80(b) | The exterior walkway in the back of the home had cement with broken pieces of wood protruding upward, several broken pieces of concrete causing a possible hazard. The exterior steps on the side of the home have broken and uneven concrete and detached bricks causing a possible tripping hazard. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The steps have been removed and have been paved flat. Photograph documentation has been retained. 2/23/23 |
03/15/2023
| Implemented |
| 6400.110(e) | At 11:32AM on 2/14/2023, the smoke detectors on each of the four floors of the home were not interconnected. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | Interconnected smoke detectors were purchased and installed. Documentation of purchase and installation have been retained. 2/28/23 |
03/15/2023
| Implemented |
| 6400.141(c)(6) | Individual #1, date of admission 8/12/2022 had an initial Tuberculin skin testing by Mantoux method completed on 2/10/2023. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | The individual was admitted to the agency without medical insurance. Documentation of obtaining insurance it has been maintained in the client's file. Going forward the provider will make all attempts to have the TB test done prior to admission and/or within 31 calendar days after admission date. Completion due dates will be placed in Google calendar, giving all admin staff reminder notifications, 30, 14, 7, and 3 days prior to the completion deadline. The medical records coordinator will be responsible for making the appointment and obtaining documentation of the appointment. |
03/09/2023
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination, completed 9/29/2022, did not include medical information pertinent to diagnosis and treatment in case of an emergency. Individual #2's physical examination, completed 7/26/2022, did not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | A request to the individual's primary care physician will be made in order to obtain medical information pertinent to diagnosis and treatment in case of an emergency. |
03/15/2023
| Implemented |
| 6400.181(e)(12) | Individual #2's assessment, completed 10/9/2022, does not include recommendations for specific areas of programming, training and services. This section states, "no recommendations at this time." | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | all assessments with ¿no recommendation", have been updated and will be sent to the support¿s coordinators by Friday, March 17, 2023. Documentation will be kept in the individual's file. |
03/17/2023
| Implemented |
| 6400.216(a) | The individuals' records were stored in an unlocked file cabinet in the dining room of the home. | An individual's records shall be kept locked when unattended.
| A new file cabinet has been purchased and installed with a lock. This file cabinet will hold the individual's records securely, ensuring that privacy is not compromised. |
02/24/2023
| Implemented |
| 6400.251(b) | Individual #1, date of admission 8/12/2022, as an emergency placement, had an initial physical examination completed on 9/29/2022. | If an emergency placement occurs, § 6400.141 (relating to individual physical examination) shall be met within 31 calendar days after placement.
| The individual was admitted to the agency without medical insurance. Documentation of obtaining insurance it has been maintained in the client's file. Going forward the provider will make all attempts to have the physical and all other regulatory procedures and test done prior to admission and/or within 31 calendar days after admission date. Completion due dates will be placed in Google calendar, giving all admin staff reminder notifications, 30, 14, 7, and 3 days prior to the completion deadline. The medical records coordinator will be responsible for making the appointment and obtaining documentation of the appointment. |
03/15/2023
| Implemented |
| 6400.163(d) | The first aid kit is stored in the unlocked closet in the dining room of the home and contains packets of Diphen and Non-Aspirin. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | The first aid kit has been placed in a locked area inaccessible to the individuals. 2/15/23 [As per the CEO, the medications have been removed from the first aid kit and the first aid kit is in a location in the home that is unlocked and accessible in the case of an emergency. (AES,HSLS on 3/22/23) |
03/15/2023
| Implemented |
| 6400.163(h) | There were two packets, of "Non-Aspirin" medication that expired in 12/2022, in the first aid kit. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | The expired medication has been removed from the home and discarded. 2/15/23 |
03/15/2023
| Implemented |
| 6400.166(b) | Individual #1's 12:00PM administration of Hydroxy HCL was initialed as administered prior to 10:00AM on 2/14/2023. Individual #2's 12:00PM administration of Loxapine 25mg and Misoprostol 10MCG were initialed as administered prior to 10:00AM on 2/14/2023. Individual #2's 8:00PM administration of Paliperidone ER 6mg was initialed as administered prior to 10:00AM on 2/14/2023. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The provider has developed a "medication during outing" procedure. This procedure includes staff taking medications with them during and outing. Individuals who require medication while out in the community will have a lock box containing their medication and the more for documentation purposes. The medication will be locked and inaccessible to individuals. |
03/15/2023
| Implemented |