| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Hand soaps throughout the home advise to contact poison control if ingested, must be replaced with non-poisonous soaps. | Poisonous materials shall be kept locked or made inaccessible to individuals. | 6400.62(a)Poisonous materials shall be kept locked or made inaccessible to individuals. The Residential Manager has replaced hand soap with a non-toxic brand and checked home for any other poisonous materials. |
07/03/2024
| Implemented |
| 6400.66 | There were no operable lights in the enclosed patio. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| 6400.66 Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The Residential Manager replaced the patio lights and checked all other lights in the home. |
07/03/2024
| Implemented |
| 6400.71 | There were no emergency phone numbers in the kitchen near the phone. | 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 has placed the telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center and ensured all numbers are posted by each telephone in the home with an outside line. |
07/03/2024
| Implemented |
| 6400.76(a) | The blinds in the basement bathroom need to be repaired/replaced.
The dryer lint tray was not clean and should be cleaned after each use. | Furniture and equipment shall be nonhazardous, clean and sturdy. | 6400.76(a) Furniture in individual bedrooms and family living areas shall be nonhazardous, clean and sturdy.
The Residential Manager replaced the broken blind and checked all other blinds to ensure compliance. The Direct Support Staff and Residential Manager will ensure the dryer lint screen is cleaned after every use. |
07/03/2024
| Implemented |
| 6400.77(b) | There were no tweezers found in the first aid kit. | 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 has replaced the tweezers in the first aid kit. |
07/03/2024
| Implemented |
| 6400.111(a) | There was no fire extinguisher in the basement area or the bedroom level. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | 6400.111(a) there shall be at least one operable fire extinguisher with a minimum 2A rating for each floor, including the basement and attic. The Residential Manager and Area Director have had fire extinguishers installed in the basement and bedroom hall area. |
07/03/2024
| Implemented |
| 6400.111(f) | There was no tag on the fire extinguisher in the kitchen. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | 6400.111(f) A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. The Residential Manager had the extinguisher rechecked with a new tag. All home fire extinguishers were checked to ensure tags are current and present. |
07/03/2024
| Implemented |
| 6400.141(c)(9) | Individual #1 is a 41-year-old male and had not had a Prostate examination at his most recent physical examination. | The physical examination shall include: A prostate examination for men 40 years of age or older. | The physical examination shall include: A prostate examination for men 40 years of age and older. The Residential Director will schedule a physical examination with a request for a prostrate exam for Individual #1 and all males over 40. |
07/31/2024
| Implemented |
| 6400.144 | Individual #1's medication box contains Nighttime cold and flu relief, but it is not listed on the MAR. The Individual's name is not on the bottle and if it belongs to individual #1. | 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.
| 6400.144 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. The Residential Manager has corrected all MARs for Individual #1 and inserted his name on medications that are over the counter drugs. The Residential Manager has checked all medications for all individuals to ensure the MARS are correct and that all medication is labelled with the individual's name. The Residential Manager will check the MARs weekly to ensure all requirements of a medication record are present including labelling with the person's name. |
07/03/2024
| Implemented |
| 6400.181(a) | Individual #1 was admitted on 03/09/24 and there was no assessment in the records completed within a year prior to admission; therefore, an Initial Assessment must be completed 60 calendar days after admission. | 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. | 6400.181(a) Each individual shall have an initial assessment within 1 year prior to or 60 days after admission to the residential home and an updated assessment annually thereafter. Using the Sunrise Community Form 046-PCS Residential Application Checklist and Form 830 Outcomes and Rights Assessment, the Program Specialist will conduct an initial assessment for Individual #1 and for all new admissions within 60 days and annually thereafter. The Area Director and Program Specialist have been retrained on the assessment tool on 7/2/24 to include the required time frames. |
07/31/2024
| Implemented |
| 6400.217 | Individual #1 did not have a signed Release of Information form in his individual records. | 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.
Using the Sunrise Community Form 046-PCS Residential Application Checklist and Form 119-PA Consent to Obtain or Release Protected Health Information, the Program Specialist will ensure that Individual #1 and all people receiving services will have the written consent for release of information including photographs, to persons not otherwise authorized to receive it. The form will be signed and in their record. |
07/31/2024
| Implemented |
| 6400.163(a) | A Medication pill was found loosely in the medication box. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | 6400. 63(a) Prescription and non prescription medications shall be kept in their original labeled containers. Prescription medications shall be labelled with a label issued by a pharmacy. The Residential Director has reviewed the MARS and each person's medications to ensure all medication is kept in its original container and labelled correctly. The Residential Manager will review the medications and MARS weekly to ensure compliance with packaging and labelling. |
07/31/2024
| Implemented |
| 6400.165(b) | Individual #1's Medication Xarelto-(2)15 mg bottles are in the medication box. The medication record lists 20mg take 1 by mouth daily. That order is not on the current electronic MAR, the paper NAR shows the last date administered was 3/11/24. The 20mg XARELTO bottle is empty. | A prescription order shall be kept current. | 6400.165(b) A prescription order will be kept current. The Residential Director has reviewed the MARS and each person's medications to ensure all prescriptions are current and match the medications to be administered. The Residential Manager will review the medications and MARS weekly to ensure compliance with prescriptions being current and matching the medications to be given. |
07/31/2024
| Implemented |
| 6400.165(c) | Individual #1's medication Divalproex 500mg tablet was filled on 1/16/24- take 1 tablet by mouth every 12 hours, and 250mg was filled on 1/8/24 take 1 tablet by mouth 2x's a day. The 500mg dosage is currently listed on the MAR and is being administered. Clarification needed and disposition of the other to avoid confusion/overdose.
Individual #1's medication Hydrocortisone lotion apply topically 4x's a day. This medication is not being administered 4x's daily and was last administered 8am on 3/20/24.
Individual #1's Medication Eucerin cream apply 1 time a day was Last administered on 3/20/24.
Individual #1's medication Tamsulosin Hcl 0.4mg capsule-take 1 capsule by mouth daily was not listed on the MAR. Could not be determined when/if this medication is currently being administered. | A prescription medication shall be administered as prescribed. | 6400. 165(c)Residential Director has reviewed the MARS and each person's medications to ensure that medication has been administered as prescribed. The Residential Manager will review the medications and MARS weekly to ensure medication has been given as prescribed. If any medication administration is found out of compliance, responsible staff will attend retraining and/or receive corrective action up to and including dismissal. |
07/31/2024
| Implemented |