| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The trash can located outside the back door did not have a lid, which was overflowing with waste. | Clean and sanitary conditions shall be maintained in the home. | Trash was emptied and can lid put back on, attachment. |
01/24/2024
| Implemented |
| 6400.80(a) | The walkway outside the kitchen door was not free from ice, snow and was a hazard. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | Walkway snow was shoveled and salt applied, attachment. |
01/24/2024
| Implemented |
| 6400.141(a) | Individual#19 annual physical exam was not complete timely, previous exam was completed 05/17/22 and not completed again until 08/31/23. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Mark received his annual physical exam on 8/31/23. |
01/24/2024
| Implemented |
| 6400.141(c)(6) | Tuberculin (TB) skin test for Individual #19 could not be determined if completed, form shows test was administered on 05/17/22 and noted it was read on 06/19/22. The nurse signed the form as read on 10/12/22. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | The TB test was administered on 5/17/22 as part of his APE. The nurse incorrectly documented the reading of the test as 6/19/22. The correct date of the reading of the TB test was 5/19/22. |
01/24/2024
| Implemented |
| 6400.163(h) | Medication (POLYVINYL SOL 1.4%) expired 08/09/2023 but was in individual #18 med box. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Expired Polyvinyl sol removed from cart and discarded in a safe manner. |
01/24/2024
| Implemented |
| 6400.165(b) | Prescribed PRN medication (IBUPROFEN 200mg) is listed on Individual #18 MAR and not kept current, not on site. | A prescription order shall be kept current. | Medication delivered to unit. |
01/24/2024
| Implemented |