| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.77(b) | At the time of the inspection, there were no antiseptic wipes located in the first aid kit. | 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. | A review of this non-compliance occurred with staff to better understand how it occurred as we have implemented a series of checks done by both supervisors and nursing staff inclusive of first aid kits. This had been done and verified just prior to licensing as part of our LII assessment. The antiseptic had been available at this location. The review found that staff had done one last check before the survey and found the expiration date of the antiseptic to be 02/28. They did not recognize this as February of 2028 and instead thought it expired on February 28th, just days before our survey. They discarded the product and were seeking replacement while individuals were away, however the survey occurred by licensing staff during this time. The item has been replaced. |
03/15/2024
| Implemented |
| 6400.112(e) | This home opened in September of 2023 and in order to be in compliance with this regulation, a sleep drill should have been conducted in February of 2024, however there was no sleep drill conducted from 9/2023 to 2/2024. | A fire drill shall be held during sleeping hours at least every 6 months. | Citations related to fire drills occurred in newly established homes with new site supervisors. In the initial opening of the homes, we failed to address fire drill scheduling as a part of the opening process. We have established a fire drill `schedule¿ that blocks out a certain week and window of time each month for drills to be completed. This is not too prescriptive such that it is predictable to those taking part in the drill, but adherence will insure that varied staff are engaging at varied times. It also specifies which months should have overnight drills. A copy of this template is attached as #3. |
03/15/2024
| Implemented |
| 6400.112(g) | The fire drills held at this home occurred between 5:27pm-9:05pm. there were no drills conducted during morning or afternoon hours.
Morning hours are 6am-12pm, and afternoon hours are from 12pm-5pm. | Fire drills shall be held on different days of the week and at different times of the day and night. | Citations related to fire drills occurred in newly established homes with new site supervisors. In the initial opening of the homes, we failed to address fire drill scheduling as a part of the opening process. We have established a fire drill `schedule¿ that blocks out a certain week and window of time each month for drills to be completed. This is not too prescriptive such that it is predictable to those taking part in the drill, but adherence will insure that varied staff are engaging at varied times. It also specifies which months should have overnight drills. A copy of this template is attached as #3. |
03/15/2024
| Implemented |