| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | There was a hole in the wall that measured 6 inches by 2inches in the hallway. In individual #2's bedroom there was a hole 1 ½ feet by 6 inches in their bedroom near their door. | Floors, walls, ceilings and other surfaces shall be in good repair. | The residential manager is responsible for this correction
The agency shall ensure floors, walls, ceilings and other surfaces shall be in good repair.
On 10/01/24 the program manager engaged property maintenance to review all surfaces at the home and replace/repair any damages. |
10/14/2024
| Implemented |
| 6400.71 | There was no emergency phone numbers in the kitchen and in individual #1's bedroom at the time of the inspection. | 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.
| The Program Manager is responsible for this correction.
The agency shall ensure that 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.
This violation was corrected on the day of the inspection |
10/15/2024
| Implemented |
| 6400.82(f) | There were no paper or cloth towels for use after handwashing in the bathroom | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | The program manager is responsible for making this correction.
A paper towel dispenser plus paper towel would be installed in the bathroom.
The dispenser has been installed. Installation date was 10/11/2024 |
10/14/2024
| Implemented |
| 6400.144 | Individual #1 was prescribed Kentoconazole 2% cream on an as-needed basis. The medication was not in the home at the time of the inspection.
The individual stated that the mother of the individual (not the prescribing physician) told them to not administer the medication. There no physician's order discontinuing the medication. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| The program specialist and medical director would be responsible to ensure this code is complied with.
The agency will ensure Health services such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
Immediate action. Upon discovery, the pharmacy was contacted to provide a refill of the Ketoconazole 2% cream. The agency is contracted with a pharmacy that only works with CLAs and the pharmacy is very efficient and does deliver medications promptly.
Additionally a review of all MARS and medication for all residents was carried out by supervisors. |
10/14/2024
| Implemented |
| 6400.166(a)(2) | Individual #2's MAR for September 2024 did not include the prescriber of the medications. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | The Agency nurse/Medical director/Program specialist is responsible for this
The agency shall ensure all Medication records reflect the name of the prescriber
The agency has completed updates to medication in MARs that do not reflect the purpose of the medication. |
10/15/2024
| Implemented |
| 6400.166(a)(11) | Individual #2's MAR for September 2024 did not include the diagnosis and or purpose for the medications. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | The Agency nurse/Medical director/Program Specialist is responsible for this
The agency shall ensure all Medication records reflect the diagnosis or purpose of the medication.
The agency has completed updates to medication in MARs that do not reflect the purpose of the medication. |
10/15/2024
| Implemented |