| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(a) | During the inspection the living room window was open and there was no screen in the window. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Facilities ordered custom screen and installed on window |
03/29/2022
| Implemented |
| 6400.141(c)(14) | Individual #1 physical date 11/15/21 is missing the medical information pertinent to diagnosis and treatment in case of emergency. The section indicates yes but does not list specifics. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Request sent to the PCP to complete the missing information on annual physical. PCP updated, initialed and dated the additional information and returned. |
03/31/2022
| Implemented |
| 6400.165 | Per MAR; Medication (atenolol tablet) for Individual #2 is to be dispensed at 8am. Mar was initialed that medication was dispensed. The medication was not dispensed at 8AM. Medication was dispensed approximately at noon on March 2, 2022 during inspection. | Documentation of medication errors and follow-up action taken shall be kept.
| Agency nurse was contacted immediately upon discovery and medication was dispensed. Practicum Observer met with employee for an additional observation and reviewed the checks and balances system. |
04/07/2022
| Implemented |
| 6400.15(b) | The agency did not use the department's most current licensing inspection instrument. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | Updated copy of the Licensing Inspection instrument obtained and will be utilized going forward. |
03/04/2022
| Implemented |
| 6400.162(b)(1) | Medication for Individual #2 that was to be dispensed at 8 am (atenolol tablet) was still located in unopened container in blister pack. Medication was signed off, however medication was not dispensed by staff or certified personnel qualified to dispense medications | A prescription medication that is not self-administered shall be administered by one of the following: A licensed physician, licensed dentist, licensed physician's assistant, registered nurse, certified registered nurse practitioner, licensed practical nurse, licensed paramedic or other health care professional who is licensed, certified or registered by the Department of State to administer medications. | Agency nurse was contacted immediately upon discovery and medication was dispensed. Practicum Observer met with employee for an additional observation and reviewed the checks and balances system. |
04/07/2022
| Implemented |