Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.64(a) | At time of inspection the placemats on the table were sticky to the touch with dried circular rings on them. There was visible debris under the refrigerator, the kitchen cabinet doors had visible drips and splashes as well as a sticky substance on the cabinet doors over the microwave. The mirrors in the home were streaked with a milky substance. Large cobwebs were in the left corner of the living room ceiling.
(REPEAT VIOLATION 12/22, 3/23) | Clean and sanitary conditions shall be maintained in the home. | The placemats are now cleaned and none sticky to touch, no dried circular rings on them. The refrigerator was pulled out and cleaned, the Kitchen Cabinet doors were cleaned and polished. Large Cobwebs in the left corner of the living room ceiling was cleaned and the wall was painted. see picture and home depot receipt emailed to kristen |
12/19/2023
| Implemented |
6400.66 | Three of the four lightbulbs in the bathroom fixture were missing making the lighting in the room inadequate. There was no lightbulb in the fixture of the poison closet, with door closed the room was dark. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| All Lightbulbs in the bathroom fixture are now replaced. There is lightbulb in the fixture of the poison closet now. see picture of all lightbulb emailed to Kristen. |
12/21/2023
| Implemented |
6400.67(b) | The far wall in the kitchen had an area of approximately six inches by 36 inches where the paint was worn and chipping. The bathroom wall near the tub and floor, behind the door was crumbling away with some debris on the floor. All small items in the home are made inaccessible to Individual #1 due to the ingestion of inedible items. The crumbling wall and chipping paint present a hazard.
(REPEAT VIOLATION 12/22, 3/23) | Floors, walls, ceilings and other surfaces shall be free of hazards. | The Far Kitchen wall is now painted. The bathroom wall near the tub and floor is now repaired. The agency has submitted written request to the apartment management to authorized Heart to Heart to carry out maintenance repair when ever needed. Attached picture and letter emailed to Kristen. |
01/02/2024
| Implemented |
6400.141(c)(13) | The physical dated 3/6/23 did not contain allergy or contraindicated medication information. The section to be completed with the information was blank. | The physical examination shall include: Allergies or contraindicated medications. | The program director wrote a letter to the PCP's office to notify them that all areas of the Physical Exam Must be completed including the allergies/sensitivities and contraindicated medications. |
12/14/2023
| Implemented |
6400.144 | Individual #1 is prescribed Carafate and Zofran. The medications were listed on the Medication Administration Record (MAR) but were not available in the home to be used as prescribed.
(REPEAT VIOLATION 3/23) | 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.
| We reached out to the doctor and the Carafate is discontinued and script given for the Zofran. see copy of Discontinued Carafate and new Zofran ordered emailed to Kristen. |
12/15/2023
| Implemented |
6400.163(a) | At time of inspection a bottle of Saline Mist nasal spray and a bottle of Sport Sunscreen were in the home for use by Individual #1. Both items had remnants of a pharmacy label but there was no information visible on the labels. All writing had been worn away, leaving administration instructions, date, individual name and dosage unable to be determined. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | Both the SunScreen and Saline mist now has their prescription labeled issued by Newhard Pharmacy. See copy of the Prescription Labeled by Newhard Pharmacy emailed to kristen. |
12/21/2023
| Implemented |
6400.165(c) | Individual #1 is prescribed Denta 5000 plus cream toothpaste. At the time of inspection Pro-sys fluoride tooth gel in an .85oz travel size toothpaste was presented as the toothpaste in use for Individual #1. There was no Denta plus cream toothpaste in the home. The December 2023 Medication Administration Record (MAR) had been initialed as administered as prescribed despite the medication not being in the home at the time of inspection.
(REPEAT VIOLATION 12/22) | A prescription medication shall be administered as prescribed. | The staff Retrained. we reached out to the doctor and obtained a refill for the Dental colgate 5000 plus is now Refilled and in the home. See copy of the script for Colgate 5000 plus emailed to Kristen. |
12/14/2023
| Implemented |