| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(a) | At the time of the home inspection, the water temperature in the bathroom sink and the bathroom tub did not exceed 70 degrees. Each time I checked the water it appeared to become cooler. The last temp taken from the bathroom sink was 66 degrees. Evelyn later sent a video after maintenance came to adjust the water temperature and it was registering at 118 degrees. | A home shall have hot and cold running water under pressure. | The water temperature has been Corrected by the maintenance person. A video of the adjusted temperature was sent to Marissa. it was 118 degrees. |
12/21/2022
| Implemented |
| 6400.112(e) | There was a fire drill held on 5/22/22 at 12:13am which was a sleep drill. There was another fire drill held on 11/3/22. The time of this drill is not able to be determined as the handwriting is ineligible. However, the PM is circled, and the word NO is circled next to the area which identified if it was a sleep drill or not. This would reflect that there were not 2 sleeps drills conducted within the time frame required. | A fire drill shall be held during sleeping hours at least every 6 months. | A sleep drill was conducted immediately to make the correction. see attached correction email to Kristen. |
12/23/2022
| Implemented |
| 6400.141(c)(3) | The individual physical exam dated 2/15/2021 did not list the immunizations. This area of the physical was left blank. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | The program director wrote a letter to the doctor to advised him of the importance of listing the Immunization on the physical Exam. see attached letter email to Kristen |
12/22/2022
| Implemented |
| 6400.141(c)(4) | The individual physical exam dated 2/9/2022 did not have hearing or vision screening. This area of the physical was left blank. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Program Director wrote a letter to the doctor advising him of the importance of completing every area of the physical including the hearing and vision |
12/22/2022
| Implemented |
| 6400.141(c)(7) | Individual did not have an annual gynecological or breast exam. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | The agency has scheduled an OBGYN appointment for this for February 9th 2023 to correct this. |
12/22/2022
| Implemented |
| 6400.141(c)(11) | The individual physical exam dated 2/9/2022 did not have the health maintenance needs, medication regimen and the need for bloodwork. This area of the physical was left blank. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | Program Director wrote a letter to the doctor advising him of the importance of completing every area of the Physical Exam. including meds regimen, blood work etc. see attached letter email to Kristen. |
12/22/2022
| Implemented |
| 6400.141(c)(14) | The individual physical exam date4d 2/15/2021 did not include medical information pertinent to the diagnosis and treatment in case of an emergency. This area of the physical was left blank. The individual also had a physical exam dated 2/9/2022 did not have medical information pertinent to diagnosis and treatment in case of an emergency. This area was blank on the physical exam. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The program Director wrote a letter to the doctor advising him of the importance of completing every area of the physical and include pertinent information to diagnosis and treatment in case of an emergency. see attached email to Kristen. |
12/22/2022
| Implemented |
| 6400.151(c)(2) | The staff had a physical exam on 9/8/22. The area where the TB results are listed, was left blank. The negative was circled, but there was no other information pertaining to the TB test and the date it was administered. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | The agency has reached out to the doctor's office that did the Physical and a copy of Chest x-ray was faxed.
Attached is the copy of Chest Xray from the doctor's office. They stated the staff had a positive PPD history that's why they did a chest Xray. Attached is the copy of the X-ray email to Kristen. |
12/29/2022
| Implemented |
| 6400.181(e)(10) | The individual annual assessment dated _7/6/2022_ did not have the lifetime medical history. | The assessment must include the following information: A lifetime medical history. | The agency corrected this by attaching the lifetime medical behind the assessment. See attached email to Kristen. |
12/22/2022
| Implemented |
| 6400.169(a) | The DSP had an initial medication administration training completed on 10/11/22. However, there were only two observations noted. First observation was on 10/11/2022 and the second observation was on 10/12/22. The staff must have 4 med observations with in 30 days of passing the exam. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | The staff was retrained by the ODP certified med trainer. Staff has now received additional 4 Medication administration Observations with a pass. |
12/29/2022
| Implemented |