Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.68(b) | The hot water temperature tested at the kitchen sink was 133.8 degrees Fahrenheit at the time of inspection. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The hot water heater temperature was turned down and now reading 117 degrees F. During the inspection process it was noted that the thermometers used by each home were not adequate for measuring water temperatures. The agency has purchased new thermometers for every home. In addition, the agency has implemented b-weekly water temperature checks in each home which will be performed by the house manager. |
07/19/2021
| Implemented |
6400.34(a) | Individual #1 was not informed of the right to a locking mechanism for the home, which is covered under regulation 32s. | 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. | The agency has updated the Individual Rights Policy and reviewed this with Individual #1.
Individual #1 was already exercising his right to have keypad access to his home. |
07/22/2021
| Implemented |
6400.166(a)(11) | Individual #1's Medication Administration Record does not include the diagnosis or purpose for their medications. | 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. | The agency has requested changes to the E-MAR system with the pharmacy that includes the ability to make changes to the MAR to add the diagnosis to each medication. In addition, new medications cannot be approved without the diagnosis being completed in the E-MAR system. |
07/19/2021
| Implemented |