| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.43(b)(1) | The overnight staff logs were not complete, and you could not determine if the staff was checking on the individuals in the home. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | A Sleep Check training was developed by the agency nurse on 9/11/19 and all staff were trained. (Attachments #5 & 21) |
09/25/2019
| Not Implemented |
| 6400.46(f) | Staff person #1's Last fire safety training was completed on 8/14/18. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Staff Person #1 was re--trained on fire safety on 10/22/19. (Attachment # 22) Going forward, the new Director of Training and training department will track and ensure all required fire safety training paperwork for all staff. |
03/01/2020
| Implemented |
| 6400.81(k)(6) | There were No mirrors found in individual #1 or individual #2 bedrooms. | In bedrooms, each individual shall have the following: A mirror. | Mirrors purchased and hung in the bedrooms on 9/26/19. (Attachment # 23)
A bi-monthly site inspection process and form will be developed and occur. Going forward, when a facility related issue is determined by the site inspection completed by the Regional Director and the Facilities Director or their designee, staff will complete a Facility Repair work ticket. The Facility Director will provide an estimated repair date based on the severity of the needed repair and ensure repairs are completed within at least 1 month unless noted why the time frame needs to be extended. |
02/01/2020
| Implemented |
| 6400.144 | Individual #1's medication Olopatadine sol 0.2% eye drop was not in the medication box. (later replaced during inspection)
Individual #1's medication Nystatin TOP POW 100,000 was not in the medication box. (later replaced during inspection) | In bedrooms, each individual shall have the following: A mirror. | Medications missing during inspection were found on site during the licensing visit and placed in the medication box.
Going forward, re-training of all house staff will occur regarding the proper maintenance, disposal of and storage of medications. |
01/01/2020
| Implemented |
| 6400.161(e) | Individual #1's medication Ducodyl tab 5mg was not in the medication box, but the medication was on the medication log. The house manager stated the medication was discontinued, but no documentation was provided to verify. | Discontinued prescription medications shall be disposed of in a safe manner. | Medication was removed same day as site visit. Going forward, re-training of all house staff will occur regarding the proper maintenance, disposal of and storage of medications. |
01/01/2020
| Implemented |
| 6400.166(a)(7) | Individual #1's medication Cepacol cgh loz 5-7.5mg was not listed on the medication log, but it was in the medication box. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | The MAR was amended to add the Cepacol medication. (Attachment #24 ) Going forward, re-training of all house staff will occur regarding the proper maintenance, disposal of and storage of medications. |
01/01/2020
| Implemented |