| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.110(f) | The Fire alarm system did not function during physical site review on 12/8/2021. The agency repaired or implemented the proper use of the system within 24 hours.
In addition, Individual#1's bedroom is equipped with a strobe and bed vibration device that is required per the individual's individual plan and the individual's health needs. The strobe did not function during the initial review. The system was re- tested the following day on 12/9/2021, the vibration device functioned, and the alarm sounded, living room strobe was lit but the bedroom strobe did not flash. | If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. | -Unannounced Fire Drill was ran by DSP with supervision of Community Home Manager ensuring that the strobe light did function (operable) in the bedroom and living room. |
12/30/2021
| Implemented |
| 6400.144 | Guaifenesin liquid 100/5ml prescribed to individual#2 to be taken as needed was not present on site. | 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.
| -Medication (Guaifenesin liquid 100/5ml prescribed to individual#2) has been Replaced by Providers Nurse. Medication now resides inside of the Individuals locked Medication Box inside of the CLA. |
12/27/2021
| Implemented |
| 6400.166(b) | Thick-it powder original to be used as directed to thicken food and beverages was not logged immediately after use. Prevail brief mis adult xlg to be billed for in an emergency were not logged as dispensed immediately after applied to individual. Depend real-fit mis lg / xl to be used as directed was not logged after use for individual#2. Scripts for all items were provided for the health services and stated on the medication administration record but were not logged when they were used or applied. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | -Thick It has been removed from the MAR Log (Provider Nurse requested from Physician) however Provider Tracks through separate tracking sheet to ensure availability.
-.Prevail brief mis adult xlg and Depend real-fit mis lg / xl have been removed from both MAR Logs (Provider Nurse Requested from Physician) however Provider Tracks through separate tracking sheet to ensure availability. |
12/28/2021
| Implemented |
| 6400.186 | The individual plan of individual#1 was not implemented as written in the field of fire safety. The most current individual support plan documented the individual has a light that vibrates during fire drills. The Current device was not set up as discussed in the plan and it is unclear if that is sufficient for the individual. The bedroom did not have an operable flashing light during the fire drill. | The home shall implement the individual plan, including revisions. | -Unannounced Fire Drill was ran by DSP with supervision of Community Home Manager ensuring that the strobe light did function in the bedroom. |
12/30/2021
| Implemented |