| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.71 | Poison control number was not listed on emergency phone lists throughout the home. | 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.
| 6400.71 Telephone numbers of the nearest hospital, police department, fire department, ambulance, and poison control center will be on or by each telephone in the home with an outside line. The Residential Manager will ensure that telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center are posted by each telephone in the home with an outside line. |
08/02/1924
| Implemented |
| 6400.77(b) | The first aid kit did not have tweezers, or a thermometer. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | 6400.77b A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors, and syrup of Ipecac if an individual 4 years of age or younger or an individual likely to ingest poisons is served.
The Residential Manager will ensure the home has a first aid kit containing antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. |
07/03/2024
| Implemented |
| 6400.81(k)(6) | There was no mirror in individual #1's bedroom. | In bedrooms, each individual shall have the following: A mirror. | 6400.81k -6 In bedrooms, each individual shall have the following: a mirror.
The Residential Manager will ensure that each person has a mirror in their bedroom. If for some reason a person does not choose to have a mirror in their room, it will be documented in their plan. Individual #1 does not like to have a mirror. There is a mirror kept in his closet when he wants to use it. His choice is documented in his plan. |
07/03/2024
| Implemented |
| 6400.110(a) | There was no smoke detector in the attic. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | 6400.110(a) - A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic.
The fire company has installed an alternative, a heat detector since the smoke detector would not have worked properly in the attic. |
07/03/2024
| Implemented |
| 6400.111(a) | There was no fire extinguisher in the attic. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | 6400.111a There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. The fire extinguisher has been installed in the attic.
Area Director will ensure that there is at least one operable fire extinguisher with a minimum 2-A rating for each floor including the basement and attic. The Area Director will ensure all homes have the appropriate fire extinguishers and smoke detectors in each area of the house required by regulation. |
07/03/2024
| Implemented |
| 6400.168(c) | Medication training of staff did not show successful completion of the medication training course, it was requested, but not provided at the inspection. Modified medication training certificates were provided. | Medications administration training of a staff person shall be conducted by an instructor who has completed the Department's Medications Administration Course for trainers and is certified by the Department to train staff. | Medication administration training of a staff person shall be conducted by an instructor who has completed the Department's Administration Course for trainers and is certified by the Department to train staff. The Sunrise RN who was slated to become the certified trainer has resigned. A nursing agency has been hired to administer medications until new trainers complete the Department's Medication Administration Course and train the staff. Three managers have been signed up to complete the course. In addition, recruitment efforts, including in an increase of starting pay, has been in effect to hire a full time nurse. |
07/03/2024
| Implemented |
| 6400.168(d) | Medication training of staff did not show successful completion of the medication training course, it was requested, but not provided at the inspection. Modified medication training certificates were provided. | A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. | All staff who administer prescription medications and insulin injections to an individual shall complete and pass the Mediations Course practicum annually. The Sunrise RN who was slated to become the certified trainer has resigned. A nursing agency has been hired to administer medications until new trainers complete the Department's Medication Administration train the Trainer Course and train the staff.
In addition, recruitment efforts including in an increase of starting pay has been in effect to hire a full time nurse. Three managers have been signed up to become certified trainers. |
07/31/2024
| Implemented |
| 6400.217 | Individual #1 did not have a signed Release of Information form in their individual record. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| 6400. 217 Written consent of the individual, or the individual¿s parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it. The Program Specialist will ensure that individual #1 and all individuals will have a written consent for the release of information, including photographs, signed by the individual and or their guardian in their record. |
07/03/2024
| Implemented |
| 6400.166(a)(4) | The medication Emergen-c was not listed on the electronic MAR for individual #1's medication record as well as the frequency of the medication, administration times of the medication, date and time the medication was administered, and the name/initials of the person administering medications. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | 6400.166(a) 4 A medication record shall be kept, including the following for each individual for whom a prescription is administered: Name of medication. The Residential Director has reviewed all the MARS and each person's medications including Individual#1 to ensure each name of each medication are listed on each person's MARS. The Residential Manager will review the medications and MARS weekly to ensure compliance with naming and labelling of all medications. |
07/31/2024
| Implemented |
| 6400.166(a)(9) | The medication Emergen-c was not listed on the electronic MAR for individual #1's medication record as well as the frequency of the medication, administration times of the medication, date and time the medication was administered, and the name/initials of the person administering medications. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | 6400.166 (a)9 A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. The Residential Director has reviewed the MARS and each person's medications including Individual#1 to ensure all medication is administered according to the prescribed frequency. The Residential Manager will review the medications and MARS weekly to ensure compliance with prescriptions and frequency of doses. |
07/31/2024
| Implemented |
| 6400.166(a)(10) | The medication Emergen-c was not listed on the electronic MAR for individual #1's medication record as well as the frequency of the medication, administration times of the medication, date and time the medication was administered, and the name/initials of the person administering medications. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | 6400.166 (a)10 A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration Times. The Residential Director has reviewed the MARS and each person's medications including Individual #1 to ensure all medication is given according to administration times. The Residential Manager will review the medications and MARS weekly to ensure compliance with prescribed administration times. |
07/31/2024
| Implemented |
| 6400.166(a)(12) | The medication Emergen-c was not listed on the electronic MAR for individual #1's medication record as well as the frequency of the medication, administration times of the medication, date and time the medication was administered, and the name/initials of the person administering medications. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration. | 6400.166 (a)12 9 A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and Time of medication administration. The Residential Director has reviewed the MARS and each person's medications including Individual#1 to ensure all medication records have the date and time of medication administration. The Residential Manager will review the medications and MARS weekly to ensure the records contain the date and time of medication administration. |
07/31/2024
| Implemented |
| 6400.166(a)(13) | The medication Emergen-c was not listed on the electronic MAR for individual #1's medication record as well as the frequency of the medication, administration times of the medication, date and time the medication was administered, and the name/initials of the person administering medications. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | 6400.166 (a)13 A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Names and Initials of person administering the medication. administration. The Residential Director has reviewed the MARS and each person's medications including Individual#1 to ensure all medication records contain the name and initials of the person administering the medication. The Residential Manager will review the medications and MARS weekly to ensure compliance with documentation of name and initials of person administering the medication. |
07/31/2024
| Implemented |
| 6400.181(f) | The program specialist did not provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | 6400.181(f) 181f The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.
The Program Specialist and Area Director have been reinserviced on the Sunrise Assessment tool Form 830_PCS, including how to conduct an assessment, and the providing of the assessment to team members at least 30 days prior to an individual plan meeting. Using Form 046 the Residential Application Checklist as a reminder, the Program Specialist will ensure the assessment is completed within 30 days and distributed to team members. |
07/31/2024
| Implemented |