| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(b) | Soiled bug traps were found in the office. | There may not be evidence of infestation of insects or rodents in the home. | The program manager will remove the soiled bug traps immediately and replace them with clean, appropriate pest control devices.
The Program Manager will verify that the area has been cleaned and sanitized following the removal of the traps.
All soiled bug traps in the office will be removed and replaced to maintain a clean and sanitary environment.
November 6: The program manager will remove the soiled traps and sanitize the affected areas.
November 7: New traps will be installed as necessary, and all pest control devices will be placed in inconspicuous, sanitary locations.
A full inspection of the site will be conducted to identify and address any additional sanitation issues.
The Program Manager will ensure that a pest control log is implemented to monitor and manage the use of traps and other pest control measures. |
11/07/2024
| Implemented |
| 6400.112(c) | For the 08/20/24 fire drill record the time of day was entered where the evacuation time minutes should have been entered. | 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. | The Program Specialist will correct the 8/20/24 fire drill record by entering the actual evacuation time in minutes, as verified by staff involved in the drill.
The Program Manager will review and approve the correction to ensure accuracy.
The 8/20/24 fire drill record will be updated with the correct evacuation time in minutes.
The Program Specialist will contact staff present during the 8/20/24 drill to confirm the actual evacuation time.
The corrected evacuation time will be recorded on the fire drill form, with the correction signed and dated by the Program Specialist.
All fire drill records from the past 12 months will be reviewed by the Program Specialist to ensure accuracy and compliance. Any errors will be corrected by December 1, 2024.
The Program Manager will ensure that all fire drill records moving forward are reviewed for accuracy before being finalized and filed. |
11/07/2024
| Implemented |
| 6400.166(b) | There is no documentation or initialing on the MAR that all prescribed medications for 8 AM were administered despite the medications being administered to Individual 2 at 8am on 11/6/2024. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The Nurse will review the MAR for November 16, 2024, and verify the administration of the 8 a.m. medications for Individual 2.
The DSP responsible for the error will complete retraining on medication documentation policies.
The MAR will be updated to accurately reflect the administration of Individual 2¿s 8 a.m. medications on November 7, 2024.
The DSP will initial the MAR to indicate the medications were administered as required.
November 7, 2024: The Nurse will review and update the MAR for compliance.
November 25, 2024: The DSP will receive retraining on Chapter 6400 medication documentation requirements and the importance of completing the MAR promptly and accurately.
A full review of all MARs for the current month will be conducted to identify any other instances of missing documentation. Any discrepancies will be corrected immediately, and all staff responsible will be retrained. |
11/07/2024
| Implemented |