| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The cabinet underneath the kitchen sink was very dirty and disorganized.
The outside of the kitchen cabinets was dirty and looked very worn.
The windows and screens in the individual's bedroom were dirty. | Clean and sanitary conditions shall be maintained in the home. | The cabinet underneath the sink was clean and reorganized. The outside of the kitchen cabinets were wiped and cleaned. The windows and screens were cleaned in Individual 1's bedroom.
Attachments 12, 13, 18. |
08/19/2024
| Implemented |
| 6400.67(a) | The oven hood in the kitchen had peeling enamel paint and the vents on the hood had significant rust.
The caulking/sealant between the bathroom sink and wall has turned black and is poor repair.
In the bathroom the caulking/sealant between the bathtub and wall is turning color and cracking in places and is in poor repair. | Floors, walls, ceilings and other surfaces shall be in good repair. | The hood range has been replaced and the caulk/sealant in the bathroom was redone around the bathroom sink and bathtub. Attachments 5,6,7,8,9,15. |
08/19/2024
| Implemented |
| 6400.76(a) | The sliding doors of the guest closet in the living room came off track when they were opened and closed. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The sliding doors were fixed and now remain on track when open and closed. Attachment 11. |
08/19/2024
| Implemented |
| 6400.144 | Robitussin DM Cough Syrup PRN was on the MAR but was not included with individual 1's medications. | 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.
| Robitussin DM Cough Syrup PRN was obtained from the pharmacy and placed in Individual 1's medication box. Attachment 17 |
08/19/2024
| Implemented |
| 6400.163(h) | Tylenol 325 mg PRN for individual 1's had expired on 02/23/24. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Tylenol 325 mg PRN was obtained from the pharmacy and placed in Individual 1's medication box. Expired medication was returned to the pharmacy. Attachment 17 |
08/19/2024
| Implemented |
| 6400.166(a)(2) | The name of the prescriber of Prilosec 40 mg was not on the MAR for individual 1. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | After review it was determined that when the medication was refilled it was completed by another physician in Individual 1's PCP's office. This name was added to the medication log. |
08/19/2024
| Implemented |
| 6400.166(a)(12) | Lubifresh Ointment was administered on 08/05/24 at 10 PM to individual 1 but was not signed off on the MAR at that time. A note has been entered into the MAR stating so. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration. | An incident report was written and noted on the medication log that the medicaiton was signed for on the incorrect date - given on 8/5/2024 but intialed as given on 8/6/2024. Attachment 10. |
08/19/2024
| Implemented |