Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.111(c) | The fire extinguisher located in the kitchen had a rating of 1A-10BC which did not meet the minimum 2A-10BC rating required by regulation. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | This violation of BroMack's misunderstanding of the Regulation. Upon this inspection, the Inspector made of aware of the Regulation as it relates to extinguisher capacity. As a result, the fire extinguisher was replaced with another that has a rating of 3A-40BC. Photographic evidence was sent to the Inspector on 3/17/2022. |
03/17/2022
| Implemented |
6400.141(c)(6) | Individual #1 had a late Tuberculin skin testing by Mantoux method. Individual #1 had a Mantoux test on 5/31/2019, then not again until 12/20/2021, which exceeds the requirement of testing every two years. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | This violation occurred as a result BroMack's assumption that the TB test was given at the time of the annual physical. This individual came to us in February of 2021 from at State Hospital setting and just had his annual physical there in December of 2020. When we scheduled his annual physical for December 2021. At that appointment, it was noticed that the TB test was overdue and we requested the test be administered. The TB test was administered on 12/20/2021 at his annual physical appointment. |
04/07/2022
| Implemented |
6400.165(b) | A tube of antibiotic ointment with a prescription label stating that it was prescribed for Individual #1 and should be applied topically on a pro re nata basis, was found in Individual#1's medication box but was not listed on the Individual's current Medication Administration Record. | A prescription order shall be kept current. | The ointment in question was prescribed in August 2021 as a result of a brush burn. We contacted the doctor and were instructed to apply antibiotic ointment that we could purchase OTC. We informed the doctor that we could not apply this medication without a prescription. The pharmacy that this individual typically uses was closed, so the prescription was called in to another pharmacy. We retrieved the medication and added it to the August MAR. However, the Residential Supervisor failed to inform his regular pharmacy of the addition of this medication, which is why this medication was not listed on the subsequent MARs. On the day of inspection, the Program Specialist added this medication to the MAR while the inspector observed. On Wednesday, April 6, 2022, the Residential Supervisor called the individual's regular pharmacy and had the ointment in question added to the MAR. |
03/11/2022
| Implemented |