| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.77(b) | There was no thermometer in the first aid kit. | 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. | Thermometer has been added to first aid kit. |
09/11/2023
| Implemented |
| 6400.112(d) | The fire drill forms dated 05/27/23, 07/24/23, 11/14/22 and 12/20/22 did not indicate in writing the designated meeting place. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | Staff will be retrained on proper way to fill out the fire drill form. |
09/11/2023
| Implemented |
| 6400.163(h) | There was an expired prescription medication in Individual #1 bedroom. This individual does self-administer their medication. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Upon admission CT admin will thoroughly inspect Individuals personal items upon arrival and monthly thereafter to ensure all unused medications are disposed of. |
09/11/2023
| Implemented |