| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | There was bug spray stored in a kitchen cabinet along with vegetable oil and ketchup. Also, according to Ind # 4 ISP, cleaners are kept locked in the home. | Poisonous materials shall be kept locked or made inaccessible to individuals. | 1. This was corrected the day of inspection; the bug spray was removed from the cabinet containing food items |
12/09/2022
| Implemented |
| 6400.62(d) | There was bug spray stored in a kitchen cabinet along with vegetable oil and ketchup. | Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces. | 1. This was corrected the day of inspection; the bug spray was removed from the cabinet containing food items |
12/09/2022
| Implemented |
| 6400.112(c) | The fire drill conducted on 5/19/2022 doesn't list documentation if the was a problem or not. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | 1. The Program Supervisor and Program Director are responsible to ensure that monthly fire drills occur and meet regulation. If a fire drill does not meet regulation a new drill is to occur. |
12/09/2022
| Implemented |
| 6400.141(c)(14) | Information pertinent to diagnosis and treatment in case of an emergency is blank on the physical dated 2/11/22 for Ind #4. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | 1. A copy of this individual¿s annual physical was sent to his PCP to request the appropriate section be filled in. |
12/09/2022
| Implemented |
| 6400.181(e)(6) | The assessment states that Ind. #4 appears to be aware of poisonous materials. The assessment needs to indicate whether the individual is safe around poisons or not. | The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | 1. Individual #4¿s assessment was amended to state that he is not safe around poisons and was sent to the team. |
12/09/2022
| Implemented |
| 6400.165(g) | Regarding psychotropic medication reviews: The reason for prescribing medication was left blank on the psychotropic medication visit form dated 9/1/22 for Ind #4. | 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. | 1. The documentation of this visit was sent to the physician to request that the appropriate information be added. |
12/09/2022
| Implemented |