| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | Individual #2 has a total income of $914.00. As this individual is tube fed and receives all of their food through their medical insurance, they can only be charged for board at a rate not to exceed 40 percent of their income. This individual is currently being charged close to 44 percent at a rate of $400, while the maximum allowed is $365.60. The difference of this amount must be reimbursed to this individual's representative payee and a new room contract must be signed with the correct amount listed. | Individual funds and property shall be used for the individual's benefit. | Rep Payee for Individual #2 (Sister) will be reimbursed the amount of $280. ($35 x 8months) .
A new Room and Board contract will be signed by all parties. It will reflect the correct amount of $365. |
09/11/2023
| Implemented |
| 6400.112(d) | The fire drill form dated 02/23/23, did not indicate in writing the designated meeting place. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | Provider will ensure that all fire drill forms are filled out in entirety. CT admin will review fire drills upon receipt. |
09/11/2023
| Implemented |
| 6400.216(a) | Individual #2 medical book was being stored in an unlocked kitchen cabinet. | An individual's records shall be kept locked when unattended.
| CT will keep individuals medical book and other records in locked cabinet when unused or attended. |
09/11/2023
| Implemented |
| 6400.24 | Individual #2 takes controlled medication clonazepam and the daily pill count for the 4 pm and 8 pm doses were not completed on 7/8/23 and 7/9/23, per federal law requirement. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | Provider will retrain staff on proper medication documentation and Federal and State laws regarding a controlled substance. |
09/11/2023
| Implemented |
| 6400.166(a)(12) | Individual #2 evening (8pm) medications for 7/8/23 and 7/9/23 were not logged off as given. The medication for these days were not present in the blister packs during the inspection. These medications include docusate liquid solution, valproic acid, clonazepam 1 mg, pravastatin 40 mg, mirtazapine 45 mg, risperidone 2 mg and artificial tears eye drops. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration. | Provider will retrain current staff on proper medication documentation. |
09/11/2023
| Implemented |