| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.110(f) | Individual #2, who is hearing impaired requires the use of a bed shaker. At the time of inspection, the device was unplugged and after being plugged back in staff were unable to enable the device was in working order. The shaker was set up and working within 24 hours. | 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. | Individual #2 - The shaker was set up and working within 24 hours (attachment #21). |
05/16/2025
| Implemented |
| 6400.112(c) | The fire drill conducted on 5/6/25, did not list if the fire extinguishers and smoke detectors were operable. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Fire Drill was completed again on 5/19/25 and reviewed by AD and Regional Director to ensure compliance (attachment #26a). |
05/19/2025
| Implemented |
| 6400.141(a) | The only complete physical on file is dated 9/25/2024 for Individual #2. The pre-admission physical on file is incomplete. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Delta uses a new admissions guide to streamline the process of screening referrals, the admission decision making process and transitioning an individual into Delta Community Supports which includes regulatory requirements (Attachment #25). |
05/16/2025
| Implemented |
| 6400.144 | Individual #1's PRN medications, Acetaminophen 325 mg, Banophen 25 mg and Ricolo lozenges were all unavailable at the time of inspection.
Individual #2's PRN medication Naproxen 500 mg and Acetaminophen 325 was unavailable at the time of inspection. | 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.
| Individual #1's acetaminophen and banophen was delivered on 5/16/25 and Ricola on 5/15/25. Individual #2's acetaminophen and naproxen were discontinued by the prescriber on 5/16/25. |
05/29/2025
| Implemented |
| 6400.151(a) | Physical last completed 9/19/2023 for Staff Person #1. Previous physical completed 9/7/2021.
Last physical completed 8/30/2023 for Staff Person #2. Previous physical completed 8/27/2021. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | The procedure for completing and monitoring staff health and physicals was reviewed and updated 6/2/25 ensuring staff physicals are completed within the required 2-year timeline by notifying staff no less than a month in advance that the document is expiring and working with the staff's manager to support completing this task (attachment #23). |
06/02/2025
| Implemented |