| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | All brand laundry tabs, Clorox brand wipes and other potentially poisonous cleaners were in an unlocked closet in the main apartment hallway accessible to individuals. | Poisonous materials shall be kept locked or made inaccessible to individuals. | WHO: Executive Director
WHAT: Poisonous materials shall be kept locked or made inaccessible to individuals
WHEN AND HOW: A lock was installed for the storage closet on 2/4/2020 |
02/04/2020
| Implemented |
| 6400.67(a) | The dresser was damaged in individual 2's bedroom, new dresser was purchased but not assembled. | Floors, walls, ceilings and other surfaces shall be in good repair. | WHO: Chief Executive Director
WHAT: Dresser was damaged in individual 2nd bedroom
WHEN AND HOW: The new dresser was removed from the box and set up for use. Al belongings of the individual were transferred from the old dresser to the new dresser and the old dresser was discarded. |
01/24/2020
| Implemented |
| 6400.68(b) | The water temperature in the apartment's bathroom tub measured at 141.8 degrees Fahrenheit. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | WHO: CEO
WHAT: Hot water temperature in bathtubs and showers may not exceed 120F
WHEN AND HOW: I followed up with the maintenance manager on 1/23/2020 regarding this and he responded by saying unfortunately, they will not be able to lower the temperature. The reason he gave was that lowering the temperature any further than where it currently is will affect the temperature of water for residents on high floors. This is due to the age and design of the building as it is centrally controlled.
After exploring the options the complex gave the agency, A faucet thermometer was installed that displays the temperature of the water dispensed from the faucet. It is very easy to use, it displays blue for water below 100 degrees Fahrenheit and turns red as soon as it hits 100 degrees Fahrenheit. |
01/23/2020
| Implemented |
| 6400.81(k)(6) | There was no mirror in individual 1 and 2's bedroom. Mirrors were recently damaged and removed per statement. Documentation of damage to mirror hardware not provided at inspection. | In bedrooms, each individual shall have the following: A mirror. | WHO: Executive Director
WHAT: No mirrors in individual's room
WHEN AND HOW: This has been addressed as all the individuals now have mirrors hanging in their rooms. This was completed on 1/22/2020 |
01/22/2020
| Implemented |
| 6400.143(a) | The physical exam on 3/19/19 notated a refusal by individual to update immunizations, no documentation was provided showing individual was trained about the need for having recommended immunizations up to date. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | All House Supervisors and staff have been coached to sign a refusal form and submit it to the office for any refusals such that it is filed in the individual's medical book.
WHO: executive director
WHAT: Train all staff and Supervisors on the need to submit a signed refusal document (signed by individual) whenever they refuse a treatment or medical appointment. Also , individual will be coached on the importance of keeping up with their medical appointments
WHEN AND HOW: Supervisors and Staff have been trained on this new procedure and this is evidenced by refusals that have been signed and documented for other individuals in the program. Training occurred on 1/27/2020 |
01/27/2020
| Implemented |
| 6400.144 | The physical exam dated 3/19/19 stated individual 1 needed a Tuberculin test completed under communicable disease precautions and that the individual was not free from them. The agency did not follow up on precautions needed to be taken due to notation individual was not free from communicable diseases.
Medication prescribed to be taken as needed for individual 1 (PRN) was not onsite at the time of inspection. Agency stated medication was discontinued but Medication Administration Record did not notate discontinuation.
The medication not onsite for individual 1 was:
Triple antibiotic ointment, Acetaminophen two 500mg tablets to be taken every 6 hours as needed for fever, diphenhydram 25mg capsule to be taken every 6 hours as needed for allergey symptoms, and Brom/pse/dm syrup 10ml to be taken as needed every 4 hours | 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.
| WHO: Executive Director)
WHAT: Follow up on precautions needed to be taken due to notation individual was not free from communicable diseases.
WHEN AND HOW - The quantiferon gold test was done on 12/31/2019 during his PCP visit and the result was negative. The document was in his book and the Registered Nurse at the agency who is privy to this information was not available at the time of the audit to present the document. His medical book has been updated with the medical record from the doctor |
12/31/2019
| Implemented |