| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(d) | The fire drill conducted on 08/19/21 had an evacuation time of 4 minutes 43 seconds The home has an extended evacuation time designated by a fire safety expert on 07/06/21 of 3 minutes. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | Review evacuation times with each site and review policy to reattempt fire drill when someone¿s evacuation time exceeds the maximum time designated by a fire safety expert. This was also explained and reviewed with the individual named in the violation |
09/20/2021
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination completed 7/15/21 did not include medical information pertinent to diagnosis in case of an emergency. This section was blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | CCI¿s Nursing Department will ensure all medical information on the individual¿s physical form is completed upon return from appointment. The individual named in the violation, physical exam was taken care of on 9/10/21 during the exit interview. |
10/31/2021
| Implemented |
| 6400.32(r) | Individual #1's bedroom door did not have a lock. Individual #2's bedroom door did not have a lock. Individual #3's bedroom door did not have a lock. Individual #4's bedroom door did not have a lock. | An individual has the right to lock the individual's bedroom door. | CCI has implemented a Door Lock Declination Statement defining each person¿s request for a door lock, the type of door lock requested to suit their needs and any additional supports needed. The declination was implemented on 9/20, giving all Program Specialist until the end of October to complete the initial declination. All declinations for CCI were completed on 10/31 and placed on each individual¿s chart. Moving forward, the Declination will then be an addendum to the Rights Assessment, completed annually thereafter, along with as needed at the individual¿s request and upon admission. Currently, all door locks based on the individual¿s preference was to be installed in all homes and bedrooms by 10/31, however, CCI is working with Barrier Protection Services Inc, who informed us that a delay was possible due to supply and demand with ordering the locks in bulk given the pandemic. As of this writing, Barrier has confirmed the locks are in and will be installation on 11/17/21 to 11/24/21. People individually identified in the violation will be completed first, along with those residing in the home of the violation. All people will be completed before their last date scheduled of 11/24/21. The declination statement also outlines the person¿s personal preferences, ability and need to assist with locking their door for personal safety and wellbeing while at home, away from home and when sleeping/personal time in their room. |
12/10/2021
| Implemented |
| 6400.166(a)(11) | Individual #1's September 2021 Medication Administration Record did not include the diagnosis or purpose for the following prescribed medications: Vitamin D, Ferrous Sulfate, Risperidone, Sertraline, and Vitamin B-12. | 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. | Upon receiving feedback after virtual tours on the second day of inspection, the Director of Nursing contacted the Pharmacy to implement a plan on all MARS moving forward. With CCI currently in the middle of a month, all changes were reflected on the October MARS, however, the month of October was used as a learning month for both CCI and the Pharmacy, to ensure all information is correct once printed and distributed to the homes. All corrections to the October MARS were made final with implementation of November MARS moving forward. A review from the Director of Nursing and her nurses, note no errors with information on the November MARS. |
10/31/2021
| Implemented |