| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | There were various poisons unlocked throughout the house including Listerine, Shampoos, Shaving creams and hand wash. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The poisons were locked up during the inspection. All poisons will be stored in a locked room when not in use. House Manager will oversee that this happens. CEO will inspect weekly. |
01/25/2019
| Implemented |
| 6400.68(b) | The water temperature in the bathroom was tested and found to be 128.6°F. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | 6400.68
Water temperature at water heater was turned down to 115 degrees. Insulation was installed to cover the water heater in order to better control a constant temperature. |
02/01/2019
| Implemented |
| 6400.77(b) | The first aid kit did not contain a thermometer. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | 6400.112
The house manager purchased a thermometer and placed in the first aid kit. He will be responsible for checking the first aid kit and adding needed supplies. |
01/01/2019
| Implemented |
| 6400.112(h) | The fire drill records did not have documentation of the designated meeting place. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | 6400.113
New fire drill forms have been created that reflect a space for designated meeting place. |
01/25/2019
| Implemented |
| 6400.113(a) | Individual #1's record did not have documentation of fire safety training. | 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. | The house manager, who is a fire safety expert, will conduct a training with the two residents and all staff. He will have a signed document along with what was trained on filed at the house. |
02/08/2019
| Implemented |
| 6400.164(b) | Individual #1's medication Benzoyl Peroxide 10% wash was on the MAR but no time for administration was listed and no signatures by staff were documented. | The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. | The medication administration person will initial and date the MAR each time medication is administered. The house manager will check that this is done on a weekly basis. |
01/19/2019
| Implemented |
| 6400.181(a) | Individual #1's admission date was 10/1/18, and there was no documentation of an intial assessment being completed within 60 calendar days, which would have been 12/1/18. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | 6400.181
The Emmaus Home Program Specialist will complete the assessment within two months of move in. Thereafter, on the anniversary of move in date. The CEO will check with the Program Specialist that this is completed. This assessment will include adaptive behavior and level of skills. These will be signed by the Program Specialist and filed in each resident's permanent binder. |
02/18/2019
| Implemented |