| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The exterior of individual#1's bedroom window had an accumulation of brown material consistent with dirt or mud toward the center of the window, a bit smaller than a CD, and a few small flying insects were observed around the window as well. | Clean and sanitary conditions shall be maintained in the home. | Window cleaned on 10/14/2021. |
11/01/2021
| Implemented |
| 6400.144 | Individual#2's MAR lists orange juice under their PRNs, with an order reading: "Have patient drink orange juice as needed for low blood sugar." At point of inspection, the house did not have orange juice on hand. As such, it cannot be determined that pharmaceutical services are being fully rendered. | 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.
| Corrected day of inspection. Individual #2 was out on an outing and the orange juice was with her. Additional supply purchased for the home as shown with picture submitted day of inspection 10/13/21 (attachment #3). |
10/13/2021
| Implemented |
| 6400.165(c) | Individual#2's MAR lists "Blood Sugar Check (Fingersticks)" with an order reading: "Check blood sugar 4 times a day (morning/noon/evening/bedtime)." At point of inspection, the house had about 16 boxes of finger sticks on hand, and the MAR was filled out for the months of September and October 2021. Staff indicated they primarily use a Freestyle Libre sensor, however, and keep the finger sticks as a backup. Staff presented documentation from Dr. Amanda Semonche dated 5/13/21 that indicates the doctor was interested in the use of the Freestyle Libre sensor if insurance approves it along with instructions to monitor the individual's blood sugar four times daily if it is approved, but this order does not reference finger sticks being kept as a backup. As such, it cannot be determined that the prescribed method of blood sugar measurement is being followed, as the MAR and the documentation from the doctor do not mirror one another. If the doctor no longer orders finger sticks, they must be DC'd and disposed of; if the doctor now orders the use of the Freestyle Libre and orders that finger sticks be kept as a backup, it must be added to the MAR. | A prescription medication shall be administered as prescribed. | Individual#2 blood sugar check order clarified by her doctor. MAR updated (attachment #5) |
10/15/2021
| Implemented |