| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | There was not lighting outside of the individual's bedroom sliding door area, which is used as an exit | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| A new outdoor light was installed on the back porch of the home |
10/24/2024
| Implemented |
| 6400.67(a) | The closet door in individual #3 bedroom requires reattachment. | Floors, walls, ceilings and other surfaces shall be in good repair. | A new curtain rod and curtain was installed. This was per the feedback of the consumers who felt it was easier for them to navigate into the closet on their wheel chairs as opposed to the closet door which sometimes required the assistance of their staff to open it for them. |
09/19/2024
| Implemented |
| 6400.77(b) | The first aid kit is missing antiseptic. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | New packs of antiseptic wipes were purchased and added to the first aid kit. |
10/28/2024
| Implemented |
| 6400.151(c)(3) | The physical dated 8/25/2023 for Staff Person #1 did not indicate whether or not they were free of communicable diseases statement. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | The caregiver returned to their physician to update her annual physical records to indicate that she is free of communicable diseases. A copy of the updated record is included in the POC emailed to the county. |
10/30/2024
| Implemented |
| 6400.24 | The individual's Room and Board Residency Agreement dated 1/10/2024 charges individual $701.06 which exceeds 72% of the maximum SSI and SSP amounts for the year 2024. The maximum charge the individual should be incurring is $694.87 as the SSI maximum is $943 and SSP rate is f $22.10 currently per Chapter 6100.686 a-1 for individual #3. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | A revised calculation was done from start of the year to August of 2024 which is the last reconciled room and board transaction. The difference of $6.188 was paid for all 8 months to the individual's account for a total of $49.50. |
10/28/2024
| Implemented |
| 6400.165(b) | Individual #1's Dicyclomine is written on the blister as 10mg as an AM dose and then as a PRN. Both are on the MAR. | A prescription order shall be kept current. | As per the Pharmacy, Nyame which was on our mar in Therap is a brand name that is no longer carried by the pharmacy a different brand name is in use now called NYSTOP. They stated this is the same medication as the Nyame just a different name. The mar was clarified and updated. |
09/19/2024
| Implemented |