| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.71 | No emergency numbers were located near or on the telephone located in the kitchen on the counter. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| Sisters best care will ensure that emergency numbers are placed next to the phone on the kitchen counter. |
03/03/2023
| Implemented |
| 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. | Sisters best care residential manager will conduct a quarterly inspection of the first aid kit using a checklist. |
03/03/2023
| Implemented |
| 6400.181(e)(14) | Assessment for Individual #2 does not include their ability to swim for water safety. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | Moving forward, the program specialist will update the individual #2 assessment to reflect the individual knowledge of water safety and ability to swim. This is an initial assessment for this individual. It has not been a year since admission.. |
03/10/2023
| Implemented |
| 6400.165(g) | There was no psychotropic review for Individual #2. Staff indicated that she started with a psychologist 9/2022 and again in January 2023. No verification of these actual visits was provided. | 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. | Moving forward sisters best residential manager will ensure documentation verifying visits is made available upon request. The residential manager will ensure that the quarterly psychotropic review is conducted by the psychiatrist. |
04/04/2023
| Implemented |
| 6400.169(d) | Staff #1 and #2 has not successfully completed the Department-approved administration course.
The record(s) of training is incomplete. Those trainings did not include the date, or the source nor documentation that the course was successfully completed. The form was not signed by the staff who completed the training. Staff must not administer medication until training is completed. | A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed. | Sisters best care will ensure staff #1 and #2 successfully completes department approved medication administration course that includes training date, source, staff signature before administering medication. |
04/30/2023
| Implemented |