| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | The cabinet under the kitchen sink was unlocked, and had 409 Cleaner, window cleaner, and comet cleaner. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Poisonous materials are always kept in a locked area which is not accessible to individuals. The cleaners were moved from under the sink and placed in a locked cabinet. When staff are hired, the practice of keeping all poisonous materials locked and inaccessible to the individuals is reviewed and is reviewed each subsequent year of employment. Please see picture of cabinet (empty) send via email to Licensing on 8.27.2020 |
08/27/2020
| Implemented |
| 6400.66 | The kitchen light was burned out. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The light was fixed on 8/27/20. All lights are now in working order and are always kept in working order. Each month the staff responsible for running he fire drill will ensure that all lights are in working order. If lights are found inoperable, staff will contact the maintenance department to request a repair. All lights are fixed ASAP within 24hrs. |
08/27/2020
| Implemented |
| 6400.68(b) | The hot water in the bathtub was 148° Fahrenheit. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The water temperature was fixed on 8.28.2020. Licensing returned on 8.31.2020 to retake the water temperature at that time, the temperature was and remains at 118 degrees. |
08/28/2020
| Implemented |
| 6400.76(a) | The chair in the living room, the back of the chair was broken and leaning backwards. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The chair was removed from the residence and thrown away. A new chair was purchased and put in its place. Please see photos sent to Licensing via email on 8.27.2020.
In the future, all staff have been instructed to inform their supervisor of any broken furniture in the home. The supervisor will make arrangements to have the furniture repaired/replaced. |
08/27/2020
| Implemented |
| 6400.77(c) | The first aid kit was missing the manual. | A first aid manual shall be kept with the first aid kit. | A new manual was purchased to replace the missing manual. Please see photos sent via email on 8.27.2020 to licensing.
KASDEC has developed a Health and Safety Team who will be ensuring that all safety concerns (first aid kit supplies, lights, fire drills, etc) are within licensing standards. A checklist will be completed by the health and safety team member each month and any concerns will be addressed within 24 hrs. |
08/27/2020
| Implemented |
| 6400.112(e) | A fire drill was Not held during sleeping hours at least every 6 months. | A fire drill shall be held during sleeping hours at least every 6 months. | A fire drill during sleeping hours was conducted on 9/25/20. A new schedule for fire drills was developed to ensure a fire drill occurs at least every six months in the future. Fire drills will be run by the staff in the residential homes. Refer to fire drill schedule sent to licensing on 9.28.2020. |
09/25/2020
| Implemented |
| 6400.141(c)(10) | The most recent physical exam form, dated 07/24/2019, does not list whether the individual #01 is free from communicable diseases. Neither the "yes" nor "no" box was checked by physician in response to "Is the person free of communicable diseases?" The line below is blank. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | Individual #01 was seen by his PCP again for his annual physical on 1.29.2020 the physician checked the box ¿free from communicable diseases¿. Staff have been instructed that when they take individuals on appointments that they must ensure all forms are completed correctly and in full before leaving. |
01/29/2020
| Implemented |
| 6400.143(a) | On the most recent physical exam form, dated 07/24/2019, the physician noted that they attempted to administer the Diphtheria/Tetanus vaccination and PPD/Mantoux test, but individual #01 refused treatment. Documentation of education provided to the individual was not maintained. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | After all medical appointment/procedure refusals, individual #01 is counseled by staff and his behavior specialist regarding the necessity of the appointment/procedure and coping skills to handle the stress of the appointment. The behavior support plan has been addended to include desensitization procedures for medical appointments. Please see behavior support plan dated 4.21.2020. Please find below the excerpt from the behavior support plan written by Staff, MA
Medical Desensitization Plan
¿Staff working with Jacob should prepare Individuals for all medical appointments prior to the appointment by explaining through words and pictures where he will be going, why and what will happen during the appointment. Staff should pack a to go bag for the appointment with healthy snacks and a drink to take with him. Staff should also bring scented lotions with them and use the lotions with him during the appointment by giving him a small amount to rub on his hands when he seems anxious or nervous. Staff should use encouraging words and head/arms/hands rubs to help reduce individuals anxiety before, during and after the appointment. Regardless of how the actual appointment goes, staff should continue to educate and congratulate individuals for whatever part he played during the appointment. This process should be continued until Jacob is no longer in need of such support. ¿ |
07/25/2019
| Implemented |
| 6400.174 | The home at 350 E. Willow Grove Ave. had very little food and did not allow for all 4 food groups. | At least one meal each day shall contain at least one item from the dairy, protein, fruits and vegetables and grain food groups, unless otherwise recommended in writing by a licensed physician for individuals.
| On 8.27.2020, staff supplied the home with any foods that were necessary to complete all four food groups.
the owner of KASDEC, does all of the food shopping because she is so health conscious. Staff buys copious amounts of fresh fruits and vegetables several times per week for the individuals. As you are aware when you are eating a fresh based diet, you should first wait until the food supply is consumed before purchasing more. The food is replenished frequently, based on the dietary needs of each individual. Ms. Hecker will continue to provide ample food from all of the food categories. Food shopping for non-perishables is completed once weekly and fresh fruits and vegetables are purchased several times a week and as needed. |
08/27/2020
| Implemented |
| 6400.31(b) | The most recent Individual Rights statement on file for Individual #01 is dated 06/27/2019. There was no signed and dated documentation that individual rights were reviewed within 2020. The documentation of rights must be reviewed and signed annually with the individual. | The home shall educate, assist and provide the accommodation necessary for the individual to make choices and understand the individual's rights. | KASDEC reviews all individual rights statements with all individuals. Individual rights were reviewed with individual #01 on 8/27/20. Education regarding this individuals¿ rights were explained to him via examples as well as reading the document to the individual. The program specialist from KASDEC is responsible for ensuring that the individuals¿ right¿s statements are reviewed with each individual each year. Please see attached updated Rights statement |
08/27/2020
| Implemented |