| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(a) | During the inspection conducted 7/28/2022, Individual #1's bedroom had a window on the right side of the room from the entrance door, which did not have a screen. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Screen was installed |
07/29/2022
| Implemented |
| 6400.106 | The furnace was inspected 2/04/2021, 8/05/2021, 1/11/2022, and 6/07/2022 but there is no documentation it was cleaned by a professional cleaning company. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| Maintenance staff will be re-certified to inspect and clean the furnace. The Certification will be kept on file. A form will be developed to document the date the Maintenance staff will clean furnaces and inspect the furnace. The furnace will be re-inspected and re-cleaned by October 1, 2022. |
10/01/2022
| Implemented |
| 6400.113(c) | Individual #1's fire safety training did not include the content of the training. | A written record of fire safety training, including the content of the training and a list of the individuals attending, shall be kept. | Descriptive content detailing what individuals are instructed on during monthly fire drills was developed and will be distributed to all homes as a resource for staff completing the drill and instructing consumers |
09/05/2022
| Implemented |
| 6400.141(c)(9) | Individual #1's most recent prostate examination was completed 6/16/2021 and not again since. | The physical examination shall include: A prostate examination for men 40 years of age or older. | Urologist appointment scheduled for 10/13/22 |
10/13/2022
| Implemented |
| 6400.165(g) | Individual #1's most recent psychiatric medication review occurred 3/15/2022. | 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. | Consumer was seen 6/25 documentation provided 7/29 |
08/29/2022
| Implemented |
| 6400.166(a)(13) | Individual #1's July 2022 medication administration record did not include name and initials of the person who administered the following medications on 7/21/2022 at 8:00am: Amlodipine 10mg tablet, Aripiprazole 30mg tablet, Aspirin Low 81mg ec tablet, Benztroprine 1mg tablet, Clozapine 100mg tablet, Clozapine 50mg tablet, Docusate Sodium 100mg capsule, Esomepra Mag 20mg DR capsule, Lisinopril 10mg tablet, Lorazepam 1mg tablet, Metformin 100mg tablet, Metoprol Tar 25mg tablet, One Touch UL Strips tests, and Ammonium Lac 12% Lot. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | Staff will be retrained on documentation of omission of medication and reporting medication errors |
09/12/2022
| Implemented |
| 6400.213(1)(i) | 213(1)ii Individual #1's record did not include identifying marks. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Error was found in electronic medical record that did not populate identifying marks to the emergency information. Error has been corrected |
09/05/2022
| Implemented |