| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Large container in between the kitchen and bedroom contained poisonous materials were not locked---corrected on site. | Poisonous materials shall be kept locked or made inaccessible to individuals. | 1. This was corrected at the time of inspection. All poisonous materials were locked. |
12/09/2022
| Implemented |
| 6400.62(c) | There was an Unknown liquid on the sink in a mug. | Poisonous materials shall be stored in their original, labeled containers. | 1. This was corrected at the time of inspection. The unknown liquid was disposed. |
12/09/2022
| Implemented |
| 6400.65 | The bedroom did not have a window. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| 1. Due to the nature of the apartment building a window is unable to be installed in this apartment. The agency is will be closing this site when a new suitable location is found |
12/09/2022
| Implemented |
| 6400.76(a) | There was a Missing handle on the bathroom cabinet door. | Furniture and equipment shall be nonhazardous, clean and sturdy. | 1. A new handle was purchased and installed on the bathroom cabinet door. |
12/09/2022
| Implemented |
| 6400.144 | Individual #11 is NPO, however the MARs list the prescribed diet as fine chopped.
Fluconazole medication label states Ind #11 take for 7 days. The MAR had initials for 7 days, but there was one pill left in the pack. | 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.
| 1. The agency contacted the pharmacy to have the correction added to Individual #11¿s MAR that her diet is NPO. |
12/09/2022
| Implemented |
| 6400.163(d) | The medication Oxybuternia 5mg was not kept locked and was sitting on the kitchen counter. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | 1. This was corrected at the time of the inspection. |
12/09/2022
| Implemented |
| 6400.163(f) | Two bottles of Omeprezole 2mg medication located in the refrigerator was not kept locked. | Prescription medications stored in a refrigerator shall be kept in an area or container that is locked. | 1. This was corrected at the time of inspection. A locked box was brought to the home and the medications were locked and placed back in the refrigerator. |
12/09/2022
| Implemented |
| 6400.163(h) | The Omeprezole 2mg (2nd bottle located in the refrigerator) medication expired on 8/31/2022. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | 1. This was corrected at the time of inspection. The expired medication was removed from the home. |
12/09/2022
| Implemented |
| 6400.165(e) | Santyl ointment for wound care administered by nurse, no documentation. PRN is listed on the medication label, but not listed as such on the MAR. The nurse discontinued the staff from applying the medication 9/11/2022. Staff on duty are not clear when the individual #11 need the ointment and there is no documentation showing that the ointment had been apply, because the nurses do not sign the MAR, therefore the agency need to have the doctors' orders on site for review. | Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received. | 1. The doctor was contacted to obtain clarification of this medication. The clarification was placed in the record. |
12/09/2022
| Implemented |
| 6400.166(a)(7) | The medication record for the Jevity 1.5 nutrient on 9/16/2022 and 9/12/2022 did not list dosage amount given for Ind. #11. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | 1. A medication error incident was filed for this documentation error and the doctor was contacted |
12/09/2022
| Implemented |
| 6400.166(a)(16) | No doctor order was on-site for the Jevity 1.5 feed. There was no clear documentation to explain the administration of this nutrient and instructions for adverse reactions. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Side effects of the medication, if applicable. | 1. The prescribing physician was contacted to obtain the prescription order. |
12/09/2022
| Implemented |