| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | The Water temperature in the bathtub was 131.5*F. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | A licensed plumber came out on 2/29/2024 and adjusted all water valves to limit hot water output to maintain between 117.8 and 118.5. Attachment documenting the adjustment was sent to the inspector. |
02/29/2024
| Implemented |
| 6400.141(c)(6) | Individual One's last TB test was completed 08/12/2021, the physical dated 11/20/2023 did not have the TB as being completed. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | The individual had a quantiferon TB gold plus blood test on 3/27/2024, results negative.
Attachment containing test and results sent to inspector. |
03/27/2024
| Implemented |
| 6400.142(a) | No dental was completed for Individual One. | 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. | On 3/18/2024 the individual was taken to a dental appointment at Penn Dental. She was extremely anxious and was not cooperative at this appointment. Currently waiting for her guardian to make an appointment with Special Smiles as it was recommended that she be under sedation for her dental appointments. Attachment with appointment refusal form sent to inspector. |
03/18/2024
| Implemented |
| 6400.181(e)(12) | On Individual One's assessment dated 11/08/23, there was no preference mentioned. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Assessment updated on 2/29/2024 with an addendum to address missing components of preferences and recommendations. Attachment containing the updated assessment sent to inspector. |
02/29/2024
| Implemented |
| 6400.165(b) | PRN SUNBLOCK on Individual One's MAR but not on site at time of inspection. | A prescription order shall be kept current. | The Nurse Manager emailed the pharmacy on 5/16/24 requesting that effective June 2024 all preprinted MAR's reflect the designated sunblock administration date parameters of April - October per physicians' orders. Additionally, the May 2024 MAR was manually corrected by the nurse Manager. Attachment containing the email and corrected MAR was sent to the inspector. |
05/16/2024
| Implemented |