| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(d) | There were food items stored in a closet along with cleaning supplies. | Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces. | This was moved immediately. The poisons were placed in another location away from food that is designated to keep poisons locked. |
12/31/2022
| Implemented |
| 6400.67(a) | A handle is missing on a drawer in the kitchen. | Floors, walls, ceilings and other surfaces shall be in good repair. | Ticket was placed on 12/19/22 and was accessed by facilities. The facilities department is waiting for the part to replace the handle. |
02/28/2023
| Implemented |
| 6400.68(c) | The only coliform water test that was on filed occurred on 11/28/22. | A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources¿ certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept. | 6400.68(c) was reviewed with the agency's facilities department. The facilities department now has a schedule to complete water testing for this home on an every 3 month basis |
01/19/2023
| Implemented |
| 6400.112(e) | Greater than 6 months between sleep drills. The most recent documented drills occurred on December 29, 2021 and October 18, 2022 | A fire drill shall be held during sleeping hours at least every 6 months. | Last overnight drill held October 2022. Next overnight drill to be held by April 2023. Overnight drills will be conducted at least every six months. |
01/31/2023
| Implemented |
| 6400.141(c)(7) | Individual #3's most recent OBGYN was completed on 10/4/2020
One was Scheduled for 12/15/22 but canceled | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | The Senior Program Associate (SPA) of home will make all appointments as soon as possible to ensure that the appointments are scheduled to not exceed a year. GYN canceled by provider and rescheduled for 1/25/23. |
01/25/2023
| Implemented |
| 6400.142(a) | The two most recent dental exams on file for individual #3 are dated 10/28/20 and 12/5/22 which is greater than 1 year apart. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | The Senior Program Associate (SPA) of home will make all appointments as soon as possible to ensure that the appointments are scheduled to not exceed a year |
01/31/2023
| Implemented |
| 6400.144 | The following PRNs for individual #3 were not present at the time of inspection:
Bisacodyl 10 MG
Loperamide (Imodium)
Metamucil PRN
Ketoconazole 2% shampoo | 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 was reordered on 12/16/22 and was delivered to the home. |
01/31/2023
| Implemented |
| 6400.163(h) | The following medications in the box if individual #3 were expired.
PRNs Indomethacin 25 MG capsules expired on 4/12/22
PRNs Meloxicam 7.5 MG tab expired on 4/19/22 | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | These medications were returned to the pharmacy. |
01/31/2023
| Implemented |
| 6400.165(b) | Ammonium Lactate 12% cream was in the medication box of individual #3 but is not on a current MAR | A prescription order shall be kept current. | Medication was added to the MAR on 12/15/22. |
01/31/2023
| Implemented |