| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | The handsoap in the bathroom was in an unlabeled container. | Poisonous materials shall be stored in their original, labeled containers. | On July 16, 2024, the program specialist and staff members took proactive steps to ensure the safety and well-being of all residents by removing all unlabeled hand soap from the bathrooms and replacing it with properly labeled and maintained soap in its original containers. |
07/16/2024
| Implemented |
| 6400.77(b) | There was no Thermometer in the first aid kit. | 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. | On July 24, 2024, the Executive Director of Lifetime Skills, in collaboration with the maintenance department of the apartment complex, made the necessary adjustments to the water temperature in both the bathtub and kitchen areas, setting it to a compliant level of 120°F. Staff will continue to assist individuals in regulating the water temperature as needed. |
07/28/2024
| Implemented |
| 6400.81(k)(6) | There was no Mirror in Bedroom of individual 1 | In bedrooms, each individual shall have the following: A mirror. | On July 20, 2024, under the supervision of the executive director, the program supervisor acquired a mirror for the second individual's bedroom and conducted a thorough site check to ensure compliance with 6400.81(k)(6). |
07/28/2024
| Implemented |
| 6400.112(c) | 5/9/2024 fire drill record does not indicate AM or PM. The 7/9/2024 drill start time (top of form) lists 4 o'clock; exact time of evacuation (middle of form) lists 6 o'clock (with a 2 min evacuation time), and also does not indicate AM or PM. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | On July 19, 2024, the supervisor of the lifetime skills program made updates to all fire drill forms. A new section was added to document the annual sleep drill, specifying whether it occurred in the morning (AM) or evening (PM). Going forward, fire drills will be conducted monthly, and staff conducting the drills will accurately record whether they took place in the AM or PM. |
07/28/2024
| Implemented |
| 6400.166(b) | No initials for any medications given on 7/14/24 - 7/15/24 for individual 1. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | On July 25, 2024, all DSPs were trained in properly documenting and initialing the MAR according to the Medical Administration policy. The Program Supervisor ensured that all staff were fully trained. |
07/28/2024
| Implemented |