| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.77(b) | There was no thermometer located in the first aid kit at time of inspection. | 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. | Moving forward Sisters Best Care residential manager will ensure that a thermometer is added to the first aid kit per regulation 6400.77(b). |
03/03/2023
| Implemented |
| 6400.141(c)(4) | Individual #1 has not had a completed eye exam and their ISP indicated a history of eye surgery. In addition, there was no record of refusal on file to indicate there was an attempt to take the individual to the eye doctors. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Sisters Best care will ensure that the individual receive an annual eye exam. |
06/15/2023
| Implemented |
| 6400.141(c)(6) | There was no record of TB screening that was completed for individual #1 on their most recent physical. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Moving forward Sisters best care will ensure that individual #1 receive an annual TB screening via lab work using the QuantiFERON TB gold plus ordered by his primary doctor to be done during his dental appointment on March 30, 2023. This will be done every two years. |
04/06/2023
| Implemented |
| 6400.181(e)(9) | Desensitization program is not indicated in Individual #1 most recent ISP or assessment. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | Moving forward, the program specialist will ensure that the desensitization plan is included in the individual assessment and will also reach out to the supports coordinator to update the ISP to reflect the desensitization plan. |
03/10/2023
| Implemented |
| 6400.165(b) | PRN medication ACETAMINOPHEN 325mg and NYSTATIN 100,000 mg was not in the Ind. #1 med box at time of inspection. | A prescription order shall be kept current. | Sisters Best care will ensure that PRN medication acetaminophen 325 mg and nystatin 100,000 units are avaivable and in the medication box. |
03/03/2023
| Implemented |
| 6400.166(b) | Medication FOR Ind. #1, FLUTICASONE NASAL 50 mcg was not signed as administered for the 8am dosage. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Sisters best care will ensure that the staff receive additional training on medication documentation.. |
03/03/2023
| Implemented |