| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.63(a) | The hot water measured 124.7 degrees Fahrenheit at 2:22pm at the kitchen sink. [Repeat violation 6/22/22 et.al] | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | Stability Home Care Services has purchased a more reliable instrument to accurately measure the water temperature down to a decimal point. |
08/11/2023
| Implemented |
| 6400.67(a) | The window located in the staff office, at the back of the home, had a crack approximately 14 inches long. | Floors, walls, ceilings and other surfaces shall be in good repair. | To ensure compliance Stability Home Care Services has made an arrangement to have the window repaired. |
08/25/2023
| Implemented |
| 6400.68(b) | The hot water measured at 126.3 degrees Fahrenheit at 2:32 PM at the bathtub in the 2nd floor full bathroom near the bedrooms. [Repeat violation 6/22/22 et.al] | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Stability Home Care Services has purchased a more reliable instrument to accurately measure the water temperature down to a decimal point. |
08/11/2023
| Implemented |
| 6400.71 | The telephone located in the livingroom of the home did not have the telephone numbers of the nearest hospital or the poison control center. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| Stability Home Care Services corrected the non-compliance by immediately adding the nearest hospital number as well as the number for poison control to the list near the telephone. |
08/11/2023
| Implemented |
| 6400.72(a) | The two windows in the staircase leading from the livingroom to the second floor, the window in the bedroom adjacent to staff office and the window in the bedroom on the right at the top of the stairs did not have screens. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | To ensure compliance Stability Home Care Services has made an arrangement to have the window repaired. |
08/25/2023
| Not Implemented |
| 6400.113(a) | Individual #1, date of admission 4/17/23, had training in general fire safety 4/18/23. [Repeat Violation 6/22/22 et.al] | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | Individuals will have general fire safety and site specific fire safety training on the day of admission. |
08/11/2023
| Implemented |
| 6400.151(a) | Chief Executive Officer #1 had a physical examination completed 5/15/20 and then again 6/15/22. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | The responsibility of the staff files check system in place has been assigned to staff member BC. |
08/11/2023
| Implemented |
| 6400.151(c)(2) | Chief Executive Officer #1 had Tuberculin skin testing by Mantoux method with negative results 5/15/20 and then again 6/15/22. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | The responsibility of the staff files check system in place has been assigned to staff member BC. |
08/11/2023
| Implemented |
| 6400.181(a) | An initial assessment for Individual #1, date of admission 4/17/23, had not been completed at the time of inspection. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | An assessment of indvidual #1 has been completed and submitted via email to individual #1 supports coordinator. |
08/11/2023
| Implemented |
| 6400.34(a) | Individual #1, date of admission 4/17/23, was informed and explained their individual rights 4/18/23. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Individuals will be informed of their individual rights as well as the process for reporting a rights violation on the day of admission. |
08/11/2023
| Implemented |
| 6400.166(a)(4) | Chlorhexidine gluconate oral rinse 0.12% was not listed as a medication on Individual #1's June 2023 Medication Administration Record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | To correct the non-compliance, the Chlorhexidine gluconate oral rinse 0.12% was entered into individual #1's MAR. |
08/11/2023
| Not Implemented |
| 6400.166(a)(5) | Chlorhexidine gluconate oral rinse 0.12% was not listed as a medication on Individual #1's June 2023 Medication Administration Record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | To correct the non-compliance, the Chlorhexidine gluconate oral rinse 0.12% was entered into individual #1's MAR. |
08/11/2023
| Not Implemented |
| 6400.166(a)(6) | Chlorhexidine gluconate oral rinse 0.12% was not listed as a medication on Individual #1's June 2023 Medication Administration Record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | To correct the non-compliance, the Chlorhexidine gluconate oral rinse 0.12% was entered into individual #1's MAR. |
08/11/2023
| Not Implemented |
| 6400.166(a)(7) | Chlorhexidine gluconate oral rinse 0.12% was not listed as a medication on Individual #1's June 2023 Medication Administration Record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | To correct the non-compliance, the Chlorhexidine gluconate oral rinse 0.12% was entered into individual #1's MAR. |
08/11/2023
| Not Implemented |
| 6400.166(a)(8) | Chlorhexidine gluconate oral rinse 0.12% was not listed as a medication on Individual #1's June 2023 Medication Administration Record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | To correct the non-compliance, the Chlorhexidine gluconate oral rinse 0.12% was entered into individual #1's MAR. |
08/11/2023
| Not Implemented |
| 6400.166(a)(9) | Chlorhexidine gluconate oral rinse 0.12% was not listed as a medication on Individual #1's June 2023 Medication Administration Record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | To correct the non-compliance, the Chlorhexidine gluconate oral rinse 0.12% was entered into individual #1's MAR. |
08/11/2023
| Not Implemented |
| 6400.166(a)(10) | Chlorhexidine gluconate oral rinse 0.12% was not listed as a medication on Individual #1's June 2023 Medication Administration Record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | To correct the non-compliance, the Chlorhexidine gluconate oral rinse 0.12% was entered into individual #1's MAR. |
08/11/2023
| Not Implemented |
| 6400.166(a)(11) | The following medications did not include a diagnosis or purpose on Individual #1's June 2023 Medication Administration record: Polyethylene Glycol, 17gm, dissolve (17gm) in 8oz of fluid, take by mouth daily and Clonazepam, 1mg tablet, take 1 tablet by mouth daily at 1pm. Chlorhexidine gluconate oral rinse 0.12% was not listed as a medication on Individual #1's June 2023 Medication Administration Record. | 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. | To correct the non-compliance, the Chlorhexidine gluconate oral rinse 0.12% was entered into individual #1's MAR and the diagnosis/purpose for the Chlorhexidine gluconate oral rinse 0.12%, Polyethylene Glycol 17gm and Clonazepam 1mg was added to the MAR. |
08/11/2023
| Not Implemented |