| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(b) | There was a mouse observed in the basement, the sanitation of this basement was not maintained. | There may not be evidence of infestation of insects or rodents in the home. | The LIFEGROUP will ensure there will not be evidence of infestation of insects or rodents in the home. The LIFEGROUP has contracted with an extermination service to visit the homes quarterly and exterminate as needed. |
08/15/2023
| Implemented |
| 6400.67(a) | There is standing water in the basement. The source of this water is unknown. | Floors, walls, ceilings and other surfaces shall be in good repair. | The LIFEGROUP will ensure the floors, walls, ceilings and other surfaces are in good repair. The organization's maintenance contact will be called to address the standing water in the basement. |
08/11/2023
| Implemented |
| 6400.76(a) | Individual #1's bedroom chest is missing knobs, causing it to be difficult to open. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The LIFEGROUP will ensure the furniture and equipment will be nonhazardous, clean and sturdy. The bedroom chest knobs have been replaced to ensure the individual can open and close the chest without difficulty. |
08/04/2023
| Implemented |
| 6400.77(b) | The first aid kit was missing a thermometer. [REPEATED VIOLATION 4/5/23] | 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. | The LIFEGROUP will ensure that all First Aid kits contain a thermometer. A thermometer was purchased and put in the First Aid kit. |
08/11/2023
| Implemented |
| 6400.141(a) | Individual #1 is not having annual physical examinations. Fourteen and a half months have elapsed between the 4/23/22 and 7/11/23 physical examinations. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The LIFEGROUP will ensure all individuals have timely annual physical examinations. An appointment list is being used to ensure medical/psych appointments are not missed. |
08/11/2023
| Implemented |
| 6400.141(c)(10) | Individual #1's 7/11/23 physical does not state if this individual is 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. | The LIFEGROUP will ensure the documentation regarding Individual #1 being free of communicable disease is completed and on site. The PM has contacted the physician to provide requested information. |
08/11/2023
| Implemented |
| 6400.144 | Individual #1's blood glucose is not being tested as required per the individual plan and behavior support plan. [REPEATED VIOLATION 4/5/23] | 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.
| The LIFEGROUP will ensure Individual's #1 blood glucose will be tested per individual's plan with staff support. Staff will be retrained on providing support to the individual and accurately documenting the results. |
08/11/2023
| Implemented |
| 6400.144 | Medication for individual #1's 8 pm evening dose was not in the medication blister packs. There were unlabeled pills in a plastic container inside of the medication box. [REPEATED VIOLATION 4/5/23] | 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.
| The LIFEGROUP will ensure that medication will not be removed from the medication blister pack until the actual time of administration. All staff will receive a memo in regard to this reminder. |
08/11/2023
| Implemented |