| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.106 | The furnace was inspected 2/02/2021, 7/20/2021, 1/13/2022, and 6/29/2022 but there is no documentation it was cleaned by a professional cleaning company. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| Maintenance staff will be re-certified to inspect and clean the furnace. The Certification will be kept on file. A form will be developed to document the date the Maintenance staff will clean furnaces and inspect the furnace. The furnace will be re-inspected and re-cleaned by October 1, 2022. |
10/01/2022
| Implemented |
| 6400.113(c) | Individual #1's fire safety training did not include content of the training. | A written record of fire safety training, including the content of the training and a list of the individuals attending, shall be kept. | Descriptive content detailing what individuals are instructed on during monthly fire drills was developed and will be distributed to all homes as a resource for staff completing the drill and instructing consumers |
09/05/2022
| Implemented |
| 6400.166(a)(11) | Individual #1's July 2022 medication administration record did not include a diagnosis or purpose for the following medications: Amlodipine 5mg tablet, Clonazepam 0.5mg tablet, Finasteride 5mg tablet, Glucosamine Vita D3 tablet, Latuda 120mg tablet, Lisinopril 40mg tablet, Omeprazole 40mg capsule, and Tamulosin 0.4mg capsule. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Program Specialists and Directors will review all Medication Administration Records to ensure that all medications prescribed have a diagnosis and reason for medication. Any found missing this information will be remediated by contacting the prescribing physician |
10/01/2022
| Implemented |
| 6400.213(1)(i) | 213(1)ii Individual #1's record did not include identifying marks. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Error in Electronic Medical record failed to update identifying marks on emergency medical information. Correction has been made to the electronic medical record. |
09/01/2022
| Implemented |