Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.72(b) | The blinds in the bathroom are damaged and need replaced or repaired. | Screens, windows and doors shall be in good repair. | Violation 72 (b) was corrected. See attachment # 13. |
04/29/2023
| Implemented |
6400.141(c)(6) | TB for individual one says negative results, but the document does not list date of administration or reading. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Violation 141 (c) was identified on individual one file the day of inspection . See attachment #14. |
04/29/2023
| Implemented |
6400.141(c)(10) | On individual one's physical, physician indication that she is free from communicable disease is not listed on form. | 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. | Violation 141 (c) (10) was completed and documented accordingly. See attachment #15. |
04/29/2023
| Implemented |
6400.213(8)(i) | Binder for individual one did not contain ISP nor sign-in sheet for this year. Most recent ISP and Sign-In was dated for 3/1/22. | Each individual's record must include the following information: A copy of the signature sheets for the initial ISP meeting.
| Violation 213 (8) (i) was completed and documented accordingly. See attachments # 16 & 17. |
04/29/2023
| Implemented |
6400.163(h) | Prescription medication NARCAN SPRAY was located in the individual one's med box. It expired on 01/13/2023. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Violation 163 (h) was removed from site and awaiting proper documentation from Physician. |
04/29/2023
| Implemented |
6400.165(b) | Medication NALOXONE 4mg nasal spray is in the individual one's med box and not listed on the MAR. | A prescription order shall be kept current. | Violation 165 (b) status is pending DC order from Physician. |
04/29/2023
| Implemented |