Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.72(a) | The screen in Individual #2's bedroom window is approximately two inches shorter than the size of the window. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | New Screen was installed in window 5/1/2022. Screen fits frame securely. |
05/01/2022
| Implemented |
6400.101 | There is a turn lock on the basement side of the door leading to the garage that would prevent egress from the garage when engaged. The garage does not have a man door. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Provider removed previous doorknob and replaced with a non-locking doorknob 4/29/2022. |
04/29/2022
| Implemented |
6400.166(a)(4) | Individual #1's April 2022 Medication Administration Record states, "Albuterol HFA 90MCG INH. The medication label states, "Proair HFA 108MCG." | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | Medication Administration Record was corrected 4/29/2022 to match the medication label. Team Lead and Program Supervisor checked MAR to ensure that all medications matched labels. |
04/29/2022
| Implemented |
6400.166(a)(5) | Individual #1's April 2022 Medication Administration Record states, "Acetaminophen 650MG Arthritis Tab take two tablets (1,300MG) by mouth every eight hours as needed." The medication label states, "Acetaminophen 500MG Tablets take two tablets by mouth three times a day." | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | On 4/29/2020, Primary Care Physician was contacted to ensure that orders were up to date and clarify . Medication Administration Record was corrected by Program Supervisor on 4/29/2022 to match the correct medication label. |
04/29/2020
| Implemented |
6400.166(a)(11) | Individual #1's April 2022 Medication Administration Record does not include the purpose or diagnosis for Melatonin. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Medication Record was corrected by Team Lead on 04/29/2020 to include purpose for Melatonin. Program Supervisor reviewed the record on 04/29/2020 to ensure accuracy. |
04/29/2020
| Implemented |