| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.111(f) | The fire extinguisher in the attic was last inspected in June 2022. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | Following the on-site inspection, a current inspected fire extinguisher that includes a current inspection tag was installed in the attic (document #7). |
08/01/2023
| Implemented |
| 6400.163(a) | PRN Motrin 300mg tab did not have a prescription label on it. It is listed on the MAR. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy for individual 2. | Immediately following the on-site inspection, the un-labeled medication was discontinued (Attachment#9) and a team discussion was conducted with provider staff and the Individual's designated person. The purpose of this team meeting was to review requirements of medication administration and medication labels, as this designated person is responsible for replacing the non-labled Motrin bottle into the Individuals medication storage container. The Designated person, legal guardian, requested the allowance for her to converse with prescribing physicians and obtain an appropriate pain reliever appropriate to the Individuals menstrual cycle symptoms. |
07/19/2023
| Implemented |
| 6400.165(a) | There was Kamea cream in the med box that did not have a prescription on it for individual 2. It does appear with directions for administration on the MAR. Provider reports that it is from the individual's mother, and that she informed them that its use is to stop as of today. | A prescription medication shall be prescribed in writing by an authorized prescriber. | Immediately following the on-site inspection, Kamea cream was removed from the med box and discontinued from the administration record (Attachment#10). A team discussion was conducted with provider staff and the Individual's designated person. The purpose of this team meeting was to review requirements of medication administration and medication labels, as this designated person is responsible for placing the Kamea cream in the Individual's medication storage container. |
07/19/2023
| Implemented |