| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.77(b) | There were no tweezers 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. | Tweezer has been placed in the our first aid kit now with extra one has back up. |
10/16/2023
| Implemented |
| 6400.82(c) | There was no bathmat located in the bathroom. | (c) For homes serving one or more individuals who have physical disabilities, at least one sink, one toilet and one tub or shower shall be adapted so that individuals who have physical disabilities have easy access and use.
| Bathroom mat has been placed in the location bathroom and staff has been trained to partially removed when an obstruction to the wheelchair and placed back after use. |
10/16/2023
| Implemented |
| 6400.163(a) | There was an unidentifiable loose pill located inside of the medication bin for individual 2. The pill was a half of pill which appeared to be split in half. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | Rehoboth Inc agency nurse has discarded loose half pill in the bill per our agency medication discard policy. |
10/16/2023
| Implemented |
| 6400.166(a)(4) | Medications bisacodyl 10 mg suppository and Ocean Nasal Spray are not located on the medication administration log but stored inside of individual 2's medication bin. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | Rehoboth Inc Agency Nurse collaborated with community care pharmacy to include PRN printed on the monthly MAR. on 10/11/2023. |
10/11/2023
| Implemented |