| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.67 | At 1:01 pm on 12/8/21, several areas spanning across the kitchen ceiling were found to be in disrepair
with cracks and peeling paint over areas where food is prepared. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Landord checked the ceiling on 12/11/21 and discussed a plan with tenant as to what will be completed after the holidays. The ceiling is structurally sound and the landlord will scrape, patch and paint the ceiling by 1/30/2022. |
01/20/2022
| Implemented |
| 6500.72(b) | At 12:51 pm on 12/8/21, the doorknob on Individual #1's bedroom door was found in disrepair, as the outside handle detached from the entire mechanism upon utilization. | Screens, windows and doors shall be in good repair. | Door knob was repaired on 12/11/2021 by landlord |
12/11/2021
| Implemented |
| 6500.34(a) | Individual #1 was informed and explained individual rights on 12/9/20. The rights document did not include the following rights: 6500.32h through 6500.32i, to privacy of possessions and to access and security of personal possessions; 6500.32m through 6500.32n, to unrestricted access of sending and receiving mail and other forms of communications, unopened and unread by others, including sharing contact information with whom they choose, and to unrestricted and private access to telecommunications; 6500.32p, to choosing with whom they share a bedroom; 6500.32r1 through 6500.32r5, to bedroom door locking provided by a key, access card, keypad code or other entry mechanism made accessible to permit them in locking and unlocking the door, to limiting access to their bedroom except in a life-safety emergency or with their expressed permission, to providing assistive technology as needed in allowing them to lock and unlock the door without assistance, to allowing easy and immediate access to their bedroom by themselves and staff persons in the event of an emergency, and to providing the primary caregiver with the key or entry device to lock and unlock the individual's bedroom door; 6500.32s, to having a key, access card, keypad code or other entry mechanism to lock and unlock an entrance door of the home; and 6500.32u, to health care decision-making. | Individual rights and the process to report a rights violation shall be explained to the individual, and persons designated by the individual prior to moving into the home and annually thereafter. | Individual Rights Policy has been updated to include 32h through 32i, 32 m through 32n,32p, 32r1-5 and 32s and 32u. The rights are verbatim from the regulations instead of summarized. This policy was updated on 12/14/21. Updated policy included in Annual resign packet and Admission packet. An annual resign packet will be reviewed with the individual on 12/30/21 |
12/30/2021
| Implemented |
| 6500.136(a)(11) | Individual #1's Medication Administration Record for December 2021 does not list the diagnosis or purpose for the prescribed Fluticasone SPR 50 mcg. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | The Health Services Coordinator will ensure that diagnosis or purpose are listed on the MAR for all medications. She will contact the pharmacy to ensure that it is added for the January Medication Administration Record. |
01/01/2022
| Implemented |