| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.77(b) | There were no tweezers in the first aid kit. | 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. | Agency house manager will immediately a have tweezers place in the first aid kit. |
11/30/2023
| Implemented |
| 6400.113(a) | Individual 1 did not have fire safety training completed upon admission. This training was first completed on 6/29/23. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | Agency will ensure that all individuals have a complete fire safety training upon admission into the agency program. |
11/30/2023
| Implemented |
| 6400.141(c)(10) | Individual 1 11/10/22 physical did not indicate if this individual was free of communicable diseases. | 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. | Agency house manager will immediately take the individual 1 annual physical conducted on 11/10/22 which did not indicate if this individual was free of communicable diseases to be amended by the individual PCP. |
11/30/2023
| Implemented |
| 6400.141(c)(14) | Individual 1 11/10/22 physical did not include information pertinent to diagnosis in case of emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Agency manager will immediately have individual 1, 11/10/22 physical form be amended to include information pertinent to diagnosis in case of emergency. |
11/30/2023
| Implemented |
| 6400.34(a) | Individual 1 did not sign a copy of the individual rights attesting that they were explained at admission. The first signed attestation of individual rights being explained was completed on 8/4/23. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Agency House manager will ensure that PS encourages Individual 1 to sign a copy of the individual rights attesting that they were explained at admission. Agency PS will amend the first signed attestation of individual rights which was explained and completed on 8/4/23. |
11/30/2023
| Implemented |
| 6400.165(c) | Individual 1's Acne medication gel 8 am daily was not in the medicine bin. | A prescription medication shall be administered as prescribed. | Agency house manager or nurse will immediately place the Individual 1's Acne medication gel 8 am which is administer daily into the medicine bin. |
11/30/2023
| Implemented |