| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | There was an unlocked cleaner under the kitchen sink. The assessment states that all poisons are kept locked in the home. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Poison discovered at the time of the the licensing inspection was removed immediately. |
11/04/2022
| Implemented |
| 6400.82(e) | There was no nonslip mat in the bathtub. | Bathtubs and showers shall have a nonslip surface or mat. | Bathtubs and showers were furnished with bathtubs/shower mats in all homes |
11/02/2022
| Implemented |
| 6400.141(c)(10) | The communicable diseases question is not answered on the current physical for Individual #1. | 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 #1 annual physical was corrected by physician to show no communicable disease. |
11/20/2022
| Implemented |
| 6400.144 | During Medication review for Individual #1, Atorvastatin 40 MG tab has been discontinued, however it was signed off as administered on 11/1/22 at 8 AM.
During Medication review for Individual #1, medication Guaifenesin 600 MG tablets were present in the medication box, however this medication is 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.
| House staff manager responsible and all house managers was retrained. |
11/07/2022
| Implemented |
| 6400.163(a) | During Medication Review for Individual #1, Norethindrone Oral Contraceptive was not in its complete packaging and had no label. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | The medication in question was placed in a labeled container. House staff managers responsible and all house managers were retrained. |
11/07/2022
| Implemented |
| 6400.165(g) | The psychotropic medication reviews for Individual #1 have not been completed every three months as required- the provided months are from February 2022, July 2022, and August 2022. | 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. | We will continue to work with physician to schedule reviews in a timely manner. Since the pandemic, its been difficult getting physicians to schedule individual #1. We discovered in our effort that the entity responsible for this review was experiencing staff shortage. They have since resolved their staffing issues and regular scheduling has resumed. |
11/07/2022
| Implemented |