| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(b) | The dryer had lint the size of a large golf ball in the filter which could cause a hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Staff are aware that the dryer lint should be cleaned out after each use of the dryer. The staff on duty this day was disciplined and all staff in this home were counseled on the importance of removing the lint from the dryer after each use |
06/25/2021
| Implemented |
| 6400.68(b) | The Hot Water temperature was measured and exceeded 120* F it was 133.5 *F at time of inspection. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The water temperature on the water tank was reduce and re-measured on 6/24/2021, water temperature is now 105.8 *F. |
06/24/2021
| Implemented |
| 6400.77(b) | The First Aid Kit did not contain tape or scissors 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. | A new First Aid kits was recently purchased for this site and the house manager assumed that it had every item necessary in it. Tape and scissors were placed in this kit on 6/25/21 |
06/25/2021
| Implemented |
| 6400.141(c)(9) | No documentation of completed prostate exam for individual #1 provided at time of inspection. | The physical examination shall include: A prostate examination for men 40 years of age or older. | The individual was not compliant with a prostate exam at the time of his annual physical examination. The PCP did not order a PSA test and it was an oversight that Keystone did not follow up with the PCP about the test. The PSA test was completed on 7/1/2021. |
07/01/2021
| Implemented |
| 6400.141(c)(14) | On individual #1's 4/15/21 physical the section pertaining to information pertinent to diagnosis and treatment in case of medical emergency was not filled out. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | At the time of the annual physical, the doctor did review all medical history and discussed pertinent info but did not fill in the spot on the form. The PCP was contacted about this and they updated the form to reflect this |
07/01/2021
| Implemented |
| 6400.166(b) | Medication BENZTROPINE 1mg for Individual #1 is being administered at 8pm, the medication was not listed on the MAR. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | During inspection, the script for this medication confirms that individual was receiving the medication as prescribed by the doctor, but there was an omission in documentation. The medication was added to the MAR immediately and the documentation was corrected. Our certified medication trainer has retrained all the staffs involved |
06/24/2021
| Implemented |
| 6400.192 | Individual #1 moved into his current residence on 3/26/21. Upon his move in his active BSP was written by his previous group home provider on 11/2/20. That BSP cited a restrictive plan including restricting access to cups, sharp objects, extra clothing, and food.
This BSP was not being followed as written by the new provider.
He did not receive an updated BSP until 6/3/21 that was non-restrictive. | The home shall develop and implement a written policy that defines the prohibition or use of specific types of restrictive procedures, describes the circumstances in which restrictive procedures may be used, the staff persons who may authorize the use of restrictive procedures and a mechanism to monitor and control the use of restrictive procedures. | Keystone Center For Family Development does not practice restrictive plan, instead KCFFD use behavior modification, positive approach and redirection. This individual receives staffing around the clock so he is always accompanied by staff for support which would limit the need for the restrictive plan. During this time staff were collecting behavioral data to submit to the Behavior Specialist so that a comprehensive nonrestrictive plan could be written to support this individual |
07/01/2021
| Implemented |