| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | Upon entering the home, there was a short hallway that did not have sufficient lighting. There was a strand of lights that were hung on the wall through the hallway, however it was very dim and difficult to see. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| On 9/20/22, the Property Manager installed a new light fixture in the hallway to ensure that there is sufficient lighting there. |
09/20/2022
| Implemented |
| 6400.82(d) | The bathroom window did not provide any privacy. There was no frost, shade, blinds or curtain on this window. The window as located on the shower wall and there was no privacy into the bathtub/shower. | Privacy shall be provided for toilets, showers and bathtubs by partitions or doors. Curtains are acceptable dividers if the bathroom is used only by one sex or only by individuals 9 years of age or younger. | Frost was applied to the bathroom window by the Program Supervisor on 9/19/22. |
09/19/2022
| Implemented |
| 6400.163(h) | Individual #6 had medication that was expired and was still in the home with current medications. These medications included Lorazepam 1mg tag to be taken 3 times a day at 8am, 2pm, 8pm. The blister pack from the month of August 2022 was still in the medicine lock box. Nayzilam 5mg, which is a nasal spray for seizures. This medication expired on 8/6/2022. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | The medication that was expired and discontinued was separated from the rest of the medications by the Program Supervisor after discovery on 9/16/22 by the licensors. They were then returned to the pharmacy on 9/19/22. |
09/19/2022
| Implemented |
| 6400.165(c) | Olanazapine 5mg tablet was prescribed to be taken at bedtime for Individual #6. I was at this home on 9/16/2022 at approximately 9:30am. At the time of medication review the nighttime medication the medication appeared to have been administered as already popped out for the night of 9/16/2022. | A prescription medication shall be administered as prescribed. | Although the blister pack showed that the medication was popped out for 9/16/22, it was not noted on the Medication Administration Record and was not administered to the individual at the wrong time. The individuals mother takes the individual on home visits and does not follow our trainings and guidelines of proper medication administration and pops out medications wherever she wants on the blister packs. The Program Supervisor contacted the pharmacy regarding this on 9/16/22 and was given new medication bottles so that the individuals mother can utilize these bottles for her home visits and won't have access to our blister packs. |
09/16/2022
| Implemented |
| 6400.166(b) | Individual #6 had a prescription medication of Diphedryl 12.5, to take 2 teaspoons every 6 hours as needed for anxiety/aggressive behaviors as evidenced by hitting, property destruction and throwing things. This medication was in the medicine box but was not on the MAR. This medication was dispensed on 7/28/2022. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The Diphedryl medication was discontinued in August 2022 and was not returned to the pharmacy then. The Program Supervisor made sure this was separated from the other medications after the licensing inspection on 9/16/22 and afterwards on 9/19/22, was returned to the pharmacy for disposal. |
09/19/2022
| Implemented |