Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.67(a) | The floor on the deck that wraps around the side and back of the home in not in good repair. There were multiple areas of the floor of the deck had peeling paint. The corner of the chain link fence at the edge of the driveway closest to the road is broken and is not in good repair. | Floors, walls, ceilings and other surfaces shall be in good repair. | The maintenance director was asked to get the deck floor peeled and repainted as well as to get the small area of the chain link fence repaired. |
08/31/2023
| Implemented |
6400.68(a) | The home does not have hot running water under pressure. The temperature of water in the bathtub measured at 92.6 degrees. | A home shall have hot and cold running water under pressure. | The Maintenance Director adjusted the temperature of the water to 120-degree Fahrenheit. |
08/30/2023
| Implemented |
6400.165(a) | Medications in the home were not prescribed in writing by an authorized prescriber. There were five packets of antacid located in the first aid kit that were not prescribed to Individual #1. | A prescription medication shall be prescribed in writing by an authorized prescriber. | House Managers will check and remove all unwanted items from new first aid kits before dispatching them to the homes and each staff is responsible to check the first aid kits to ensure that only required items remained in the first aid kits. |
08/30/2023
| Implemented |
6400.165(g) | Individual #1 is prescribed medications to treat symptoms of psychiatric illness. Individual #1 had reviews of these medications on 11/17/22 and 6/26/23. These reviews did not include the reason for prescribing the medication. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Staff doing appointments will ensure that pertinent sections of the forms are completed correctly before leaving the appointment. |
09/05/2023
| Implemented |
6400.166(b) | Individual #1 is prescribed Geri-kot 8.6mg tablet, take one tablet by mouth twice a day. The 8PM signature blocks on the Medication Administration Record(MAR) for 8/22/23 through 8/29/23 appear to have had a line drawn through them and then erased and staff initials entered after being erased. The initials of the person administering the medications were not recorded at the time the medication was administered. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | A remediation was done with the staff member who inadvertently drew the line on the medication log and attempted to erase the line. All staff members were told to be cognizant of the medication logs and to avoid making any markings on the medication logs. |
09/05/2023
| Implemented |
6400.207(4)(I) | Individual #1 is prescribed Lorazepam 0.5mg, take ½ tablet by mouth every 6 hours as needed for anxiety. There is no written protocol available to address how and when this medication is to be administered. | A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition. | The CEO will accompany individual #1 to the next medication review and request that the psychiatrist provides a written protocol for the medication in question. If the psychiatrist is reluctant to provide a protocol, then the CEO will look at other options such as requesting a discontinuation of the medication and prescribing a new medication to replace the discontinued medication. |
08/31/2023
| Implemented |