| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | An over-the-counter bottle of Vitamin C 500mg supplement pills was observed in the top left drawer under the counter in dining room. It did not have a prescription label and staff was unsure whose it was or why it was in that location. As, Individual #1 does not have full poison awareness per their ISP, poisonous materials must be inaccessible in this home. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Vitamin C was taken off site. All medications belonging to participants have labels on them. All medications are stored in a locked and labeled box inside of a locked closet. |
09/01/2021
| Implemented |
| 6400.64(a) | A glue-based rodent trap found in a basement utility closet was caked with black material that may have been dirt, grime, dust, or waste, as well as many dead insects. Agency staff disposed of the trap at time of inspection. A disposable red plastic cup was found in a cabinet above the refrigerator, coated with red drink residue all around its interior, and was disposed of by agency staff at point of inspection. Another disposable red plastic cup was found uncovered, filled with ice whose light brown color indicated previous use, and was disposed of by staff at point of inspection. | Clean and sanitary conditions shall be maintained in the home. | Staff will maintain household cleanliness as a part of their daily inspection. |
09/03/2021
| Implemented |
| 6400.65 | The house's basement bathroom has inadequate ventilation. It has no mechanical vent to draw moisture out and no openable window, just the central air vent. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Existing window access has been updated for ventilation by landlord. |
09/03/2021
| Implemented |
| 6400.76(a) | Individual #2's bedroom bureau's top drawer is its missing handle. The first four drawers from the top of the bureau are partially out of their tracks, resting on the drawer cutouts in the frame of the bureau, making it difficult to safely or easily pull the drawers out and push them back in. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Drawer pulls were replaced and the track was fixed. |
09/03/2021
| Implemented |
| 6400.144 | Individual #1's Fluticasone spray (50mcg) is ordered, per their MAR, to be administered via two sprays in each nostril daily at 8AM. Their August 2021 MAR, however, does not indicate it was administered at all, though their July 2021 MAR shows daily administration. Also, on their August 2021 MAR, the box for the 8/9/21 administration of their ammonium lac. lotion was blank, without either a signature showing administration or a notation showing a missed dose. It cannot be determined that prescribed orders are being followed, and as such it cannot be determined that pharmaceutical services are being fully rendered. | 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.
| MAR will be inspected daily to make sure that medications are given as per physicians order. |
09/03/2021
| Implemented |
| 6400.181(e)(8) | Assessment doesn't contain details on the individual #1's ability to evacuate the home in the event of a fire. It should indicate whether he is able to evacuate on his own or if he needs any assistance.
(Assessment states "he responds to the sound of smoke detectors by evacuating in less than 2 mins.") | The assessment must include the following information: The individual's ability to evacuate in the event of a fire. | Statement was added to the assessment stating that the individual is able to evacuate independently. |
09/03/2021
| Implemented |
| 6400.165(g) | Individual #1, who takes psychotropic medication, has not had a psychotropic medication review from the time of his 5/28/21 admission through today's 9/1/21 inspection. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Due to Covid 19 Pandemic; we were placed on the waiting list at Merakey Mt Airy for an assigned psychiatrist. At this time, Individual #1's psychotropic medications are being maintained by his PCP. Staff will call weekly for any emergency openings. |
10/01/2021
| Implemented |