| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | A white viscous material consistent with hand soap was found in a decorative pumpkin soap dispenser on the sink in the bathroom. Poisons must be kept in their original labeled packaging. | Poisonous materials shall be stored in their original, labeled containers. | The citated material has been replaced by a new bottle of hand soap in its original packaging. The correction was implemented by the house manager. |
12/16/2021
| Implemented |
| 6400.72(b) | The left window in the living room cannot remain fully open; when opened and let go, it quickly falls down to about a quarter of the way open, where it stops. That window's screen is loose all around its perimeter and duct taped to the frame at its bottom. In Individual 2's bedroom, the screen of the window on the left is disconnected from its frame and rises with the window when opened, bunching up as it is lifted. The right window in that same bedroom has a screen that is disconnected at its bottom, with the screen material folded over and resting on the bottom of the window frame. | Screens, windows and doors shall be in good repair. | Window maintenance and repair as well as screens repair had been conducted and completed by landlord on 12/29/21. |
12/29/2021
| Implemented |
| 6400.141(b) | Individual 2's physical was not signed by a physician. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Individual 2's physical form has been reviewed and signed by the physician on 2/3/22. |
02/03/2022
| Implemented |
| 6400.141(c)(10) | It could not be determined if Individual 2 was free of communicable diseases. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | Individual 2 Primary Care Physician was contacted by the Program Specialist and the annual physical form was resubmitted for completion. |
02/03/2022
| Implemented |
| 6400.141(c)(14) | Individual 2's file did not include information pertinent to diagnosis. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Program specialist reviewed individual 2 file and update diagnosis information to ensure consistency across.
Annual Physical form was resubmitted to the PCP for update to disclose individual diagnosis. Completed on 1/14/2022 |
02/03/2022
| Implemented |
| 6400.141(c)(15) | Individual 2's file did not include information pertinent to the individual's diet requirements. | The physical examination shall include:Special instructions for the individual's diet. | Program Specialist reviewed individuals 2 files and updated her diet as per her annual Physical.
Annual physical form has been updated with individual 2 diet information on 1/14/2022 |
01/14/2022
| Implemented |
| 6400.142(a) | Individual 2's file did not include information regarding the individual's dental health/status. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Program Specialist resubmitted the annual dental form to dental office to be completed with accurate dental health status. |
02/03/2022
| Implemented |
| 6400.166(a)(11) | There are eleven medications listed on Individual 2's December 2021 MAR; all but one do not indicate a diagnosis or purpose for the medication. The exception is their PRN ibuprofen, which the MAR states is to be taken for pain. | 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. | Program specialist contacted the pharmacy on 1/10/2022 and asked that the diagnosis be added to the MAR. Pharmacy had indicated that prescribing doctors did not indicate diagnosis code to allow such mention on MAR and will gradually work to address the issue on all individuals supported by WLI. Pharmacy reaches out to different prescribing Doctors to request the different diagnoses codes prior to sending the monthly medications. MAR's are being updated as they receive answers/feedbacks from doctors. Target completion date is 07/01/2022. |
02/03/2022
| Implemented |
| 6400.166(b) | Individual 2's medications were reviewed. A blister pack for the individual's Quetiapine 400mg medication showed that the 12/13/21 8PM dosage had been removed from the pack, but the 12/13/21 8PM log on the individual's MAR was blank, missing the administering staff member's initials. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Staff was identified and retrained on steps of medication administration. A practicum was completed on 12-21-2021. |
12/21/2021
| Implemented |