| 6400.81(k)(6) | On 10/10/2023 at 11:20am, individual #1's bedroom did not contain a mirror. | In bedrooms, each individual shall have the following: A mirror. | PM will ensure all bedrooms have a mirror in it. If it cannot, the PM will communicate with the PS and an ISP correction will be done documenting that it cannot have a mirror in it. Both PM and PS will be trained on this by the OD by 11/15/22. This will also be checked and documented by the PM on the physical site checklist that is completed monthly for 6 months. |
11/15/1905
| Implemented |
| 6400.32(d) | On 10/10/2023 at 11:10am, instructions regarding the administration of individual #1's medications were written on the whiteboard in the unlocked staff office. Because of the location of these instructions, any person entering the home would have had access to this personal information. The written instructions listed individual #1's initials and stated "supp, every 1 hr for 4hr: 1st 5:30pm, 2nd 6:30pm, 3rd 7:30pm, 4th 8:30pm. Lactulose every 3 hrs, 3 does: 1st 5:09, 2nd 8:09, 3rd 11:09. No BM, Call [House Manager #1]." | An individual shall be treated with dignity and respect. | The staff office door will be kept locked at all times so personal information cannot be seen. All staff will be retrained that the office door will be locked at times by the PS by 11/22/23. This will also be checked and documented by the PM on the physical site checklist that is completed monthly for 6 months. |
11/22/2023
| Implemented |