Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.64(a) | Pungent odor coming from Individual 1's bedroom on the second floor. This odor was extremely strong even with facial masks worn by inspector. | Clean and sanitary conditions shall be maintained in the home. | The Life Group will ensure that clean and sanitary conditions will be maintained in the home. The soiled mattress was removed from the home and discarded. a new mattress was brought and a waterproof mattress pad was purchased to use on the bed. The room was thoroughly cleaned and room deodorizer was purchased to use in the room. |
04/10/2023
| Implemented |
6400.64(a) | There is an unidentifiable brown stain on second floor couch. | Clean and sanitary conditions shall be maintained in the home. | The LIFE Group will ensure clean and sanitary conditions will be maintained in the home. On the day of inspection, the couch slipcover was washed to eliminate the stain. |
04/05/2023
| Implemented |
6400.67(a) | The floor planks on second floor hallway are tearing and coming up from the surface. | Floors, walls, ceilings and other surfaces shall be in good repair. | The Life Group will ensure that the floors, walls, ceilings and other surfaces are in good repair. The floor planks were repaired by the contractor to ensure the planks are even and sturdy. |
04/14/2023
| Implemented |
6400.67(b) | The shower knob on third floor bathroom fell off when attempted to turn water on/ | Floors, walls, ceilings and other surfaces shall be free of hazards. | The LIFE Group will ensure that all surfaces will be free of hazard. The plumber repaired the shower knob to ensure it does not fall off when the water is turned on or off. |
04/21/2023
| Implemented |
6400.72(a) | There is no screen in second floor hall window. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | The LIFE Group will ensure all windows will be securely screened. A screen was purchased for the 2nd floor window and inserted in the 2nd floor window. |
04/06/2023
| Implemented |
6400.77(b) | There were no scissors in first aid kit at the time of inspection. | 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 LIFE Group will ensure that all First Aide kits contain all items per the 6400 regulations. The original pair of scissors was replaced with a new pair of scissors to make the First Aide kit complete. |
04/05/2023
| Implemented |
6400.81(k)(2) | Individual 2's bed was covered with clothes and other materials, making it impossible to lay comfortably in bed. | In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. | The LIFE Group will ensure all bedrooms have a clean, comfortable and solid foundation. The consumer prefers to have his personal items on the bed at all times. .The Program Specialist and the Program Manager will work with the consumer to get him to understand that by removing items from his bed, he will have a more comfortable surface to sleep on. |
04/08/2023
| Implemented |
6400.81(k)(3) | There are no bed linens on Individual 2's bed. | In bedrooms, each individual shall have the following: Bedding, including pillow, linens and blankets appropriate for the season. | The Life Group will ensure that each bed has bedding, pillows, linens and blankets that are appropriate for the season. On the day of inspection the individual had soiled the bed the night before and the the staff took off the bedding to let it air out. The soiled mattress was replaced and bedding as per 6400 regulations was put on the bed. |
04/10/2023
| Implemented |
6400.82(e) | The bathroom in basement does not have a nonslip mat. | Bathtubs and showers shall have a nonslip surface or mat. | The Life Group will ensure that bathtubs and showers have a non-slip surface or mat. Although the basement bathroom is not used by consumer or staff, a bathmat was purchased and put in place to remain in compliance with the 6400 regulations. |
04/10/2023
| Implemented |
6400.144 | The following medications were not present during the medication review for Individual #2: Ensure (to be taken daily), Total block SPF 65. | 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 LIFE Group will ensure that prescribed medication and supplements be provided as ordered. The Director contacted the Pharmacy and doctor to get a supplement that was more readily available than the one originally ordered or discontinued. The sunblock was changed to SPF 50. A new MAR was sent to reflect the change. |
04/06/2023
| Implemented |
6400.216(a) | Individual program books with confidential information were stored in an unlocked hall closet on the second floor. | An individual's records shall be kept locked when unattended.
| The Life Group will ensure that all individuals records be kept locked when unattended. The Service notes book was relocated to the site office. A sign is posted for all staff to remind them to lock up the books after use. This office is kept locked when not in sure. |
04/05/2023
| Implemented |
6400.163(a) | Loose unidentified medications were stored inside clear non latex gloves. | 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 Life Group will ensure that all medications be kept in their original containers. The medication found on the day of the inspection was medication that the individual refused. The medication was properly discarded. |
05/12/2023
| Implemented |
6400.163(h) | Old medications were stored in a closet in one medication bin and not disposed properly. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | The Life Group will ensure that discontinued or expired medication will be destroyed in a safe manner according to Federal and State Statues and regulations. On the day of the inspection the old medication was taken to Walgreens and put in the receptacle for discarded medications by the Director. |
04/05/2023
| Implemented |
6400.165(b) | Regarding the medication review for Individual #2: The MAR states to take two tablets of Therems Multivitamin at 8 AM, however, the blister pack states to take one tablet at 8 AM. | A prescription order shall be kept current. | The Life Group will ensure that all Prescription orders are kept current. On the day of the inspection the Pharmacy was called for clarity of the order and a new MAR and blister pack was sent to the home to reflect the correct order of Therems Multivitamin take 1 tablet at 8am. |
04/24/2023
| Implemented |
6400.165(b) | Regarding Medication review for Individual #2: The MAR states to take two Topiramate 200 mg at bedtime, however the blister back states to take one at bedtime. | A prescription order shall be kept current. | The Life Group will ensure that a prescription order will be kept current. on the day of the inspection the Director called the pharmacy and the ordering physician to get clarification of the order. The Pharmacy sent an amended MAR to match the Pharmacy label. |
04/05/2023
| Implemented |
6400.166(b) | Regarding the medication review for Individual #2: Ziprasidone 80 MG was not signed off as administered on 4/1/23 at 8 PM, 4/2/23 at 8 PM, 4/3/23 at 8 AM, 4/4/23 at 8 AM, and 4/5/23 at 8 AM. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The Life Group will ensure that all medication administration signatures are completed at the time of administration. The Program Manager reviewed the documentation errors with the staff involved to resolve the error. |
04/06/2023
| Implemented |