| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | On 10/5/22, the hot water temperature of the bathtub in the bathroom located in the bedroom hallway measured 135.5°F at 10:40 AM. [Repeat violation 11/9/21 et al.] | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The Provider has purchased new thermostatic faucets and shower heads for the bathroom to regulate water temp for all apartments. |
10/25/2022
| Not Implemented |
| 6400.113(a) | Individual #1's admission date is 5/17/22. Their initial fire safety training was completed on 5/19/22. Additionally, Individual #1's fire safety training completed on 5/19/22 did not include the designated meeting places outside of the building or within the fire safe area. | 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. | All individuals, 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. |
10/25/2022
| Implemented |
| 6400.141(c)(1) | Individual #1's physical examination completed on 3/17/22 did not include a physician's review of their previous medical history. | The physical examination shall include: A review of previous medical history. | As a result of violation 141c The Provider has implemented a new form for physical examinations for all clients. The new form includes previous medical history. |
10/25/2022
| Implemented |
| 6400.141(c)(11) | Individual #1's physical examination completed on 3/17/22 did not include an assessment of their health maintenance needs or recommended bloodwork intervals. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | As a result of violation 141c The Provider has implemented a new form for physical examinations for all clients. The new form includes health maintenance needs or recommended bloodwork intervals. |
10/25/2022
| Implemented |
| 6400.141(c)(15) | Individual #1's tuberculin skin test via Mantoux method read with negative results on 10/28/21 did not include the name or credentials of the person reading the test results. | .141(d): Immunizations, vision and hearing screening and tuberculin skin testing may be completed, signed and dated by a registered nurse or licensed practical nurse instead of a licensed physician, certified nurse practitioner or licensed physician's assistant. | As a result of violation 141c The Provider has implemented a new form for physical examinations for all clients. The new form includes an area for TB mantoux reading and credentials of the person reading the results. |
10/25/2022
| Implemented |
| 6400.181(e)(10) | Individual #1's assessment completed on 7/14/22 does not include a current, up-to-date lifetime medical history. [Repeat violation 11/9/21 et al.] | The assessment must include the following information: A lifetime medical history. | The assessment must include the following information: A lifetime medical history. |
10/25/2022
| Implemented |
| 6400.214(b) | On 10/5/22 at 11:06 AM, it was found that the following records for individual #1 were not located on site: their most recent physical exams, dental exams, and psychiatric medication reviews. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| The provider has placed records including but not limited to physical and dental exams for all individuals in the residential home. |
10/25/2022
| Not Implemented |
| 6400.32(r)(1) | Individual #1 signed a "Lock Declaration" document on 6/1/22, requesting a door lock. On 10/5/22 at 10:50 AM, it was observed that Jonathan's bedroom door lock had a privacy door lock that can be unlocked from the outside with a straight edge, such as a fingernail, screwdriver, credit card, etc. | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | An individual has the right to lock the individual's bedroom door. |
10/25/2022
| Not Implemented |
| 6400.34(a) | Individual #1 was informed and explained their rights on 5/18/22. The rights document did not include the following: 6400.32c···the right to be free from exploitation and abandonment; 6400.32n···the right to unrestricted and private access to telecommunications; 6400.32r2···the right to limiting access to their bedroom except in a life-safety emergency or with their expressed permission; and 6400.32s···the right to having a key, access card, keypad code or other entry mechanism to lock and unlock an entrance door of the home. | 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. | The Provider has updated the individual rights form and reviewed with all clients. |
10/25/2022
| Implemented |
| 6400.165(g) | Individual #1's psychiatric medication review completed on 8/9/22 did not include the reason prescribing the medications. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. |
10/25/2022
| Implemented |
| 6400.213(1)(i) | Individual #1's religious affiliation was left blank on the face sheet and was not included elsewhere within the record. | .213(1)(iv) Each individual's record must include the following information: Personal information, including: (iv) The religious affiliation. | Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. |
10/25/2022
| Implemented |