| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.71 | Emergency telephone numbers were not on or by the telephone located in the home living room. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| The telephone numbers to the nearest hospital, emergency room, police department, fire department, ambulance, and poison control centers are kept by each phone telephone in the home with an outside line. The phone numbers were moved from a wall near the phone to next to the phone on the day of licensure. Please see the photo sent via email to Licensing on 8.27.2020. The staff in the homes have been instructed to ensure that the emergency numbers stay by the phone at all times. |
08/27/2020
| 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. | On 8.27.2020 a thermometer was placed in the first kit. Please see the photos sent via email to Licensing on 8.27.2020.
KASDEC's new Health and Safety Team members will inspect each first aide kit for all necessary contents. This will be completed on a monthly basis. Any missing items will be replaced within 24 hrs by KASDEC management staff. |
08/27/2020
| Implemented |
| 6400.112(e) | Fire Drills: 1651 Mt. Airy Ave. - 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 9/19/20. 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. See attached Fire drill Schedule. |
09/19/2020
| Implemented |
| 6400.144 | Medication SILTUSSIN SA 100mg was located in the individual #2's medication box but not listed on the MAR. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| The medication was immediately removed from the medication box on 8.26.2020. Please see photo sent via email to Licensing on 8.27.2020. Please note that this was a PRN medication that was no longer needed and was not given.
A health and safety team member who is also medication administration certified is responsible for checking the medication boxes to ensure only the medications that are prescribed and on the MAR are in the medication box. This will occur monthly. |
08/26/2020
| Implemented |