| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.62(d) | At the time of inspection there was a bottle of all-purpose bleach stored among the additional food supply in the basement. Also, while walking into the basement there was a shelf with saltine crackers and other household cleaners. | Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces. | During inspection the bottle was removed immediately to ensure the safety of the individual. Life share specialist reminded provider of expectation of having chemical separate from food products. |
12/13/2022
| Implemented |
| 6500.64(a) | The tub had a mold like substance on the tiles of the shower. The top of the bathroom wall was covered in dust and a brown substance which resembled water stains in the top corner of the walls. In addition to the dust and stains there were also dead insects in the top corner of the walls. Clean and sanitary conditions shall be maintained. | Clean conditions shall be maintained in all areas of the home. | A life sharing specialist met with the provider and reviewed cleaning & cleanliness expectations |
10/30/2022
| Implemented |
| 6500.67 | The stove in the kitchen was broken. The handle was laying on the stove top. The door was being held shut with silver duct tape. This is a hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Due to the provider¿s rental agreement the landlord was required to be contacted to repair any needs of the home. The landlord was contacted and provided a formal request for repair. The center has requested repairs be completed by 12/20/2022. |
12/20/2022
| Implemented |
| 6500.73 | The handrail on the interior of the home which was on the stairwell from first level of the home to the second level of the home was not secure. The first attachment to the wall was broken and it was shaky when going to hold the railing to walk up the steps. | An interior stairway exceeding two steps that is accessible to individuals, ramp and outside steps exceeding two steps, shall have a well-secured handrail. | Due to the provider¿s rental agreement the landlord was required to be contacted to repair any needs of the home. The landlord was contacted and provided a formal request for repair. The center has requested repairs be completed by 12/20/2022. |
12/20/2022
| Implemented |
| 6500.78(a) | The walkway to the home was a wooden stairwell with a wooden railing. A couple of the wooden boards were loose. There were also wooden spools on the railing which were not attached to the railing. These spools were dangling out toward the walkway causing a potential hazard. | An outside walkway that is used by individuals shall be free from ice, snow, obstructions and other hazards. | Due to the provider¿s rental agreement the landlord was required to be contacted to repair any needs of the home. The landlord was contacted and provided a formal request for repair. The center has requested repairs be completed by 12/20/2022. |
12/20/2022
| Implemented |
| 6500.109(d) | The fire drill dated 1/25/22 has the time of the drill listed as "AM", with no specific time documented. The fire drill dated 7/12/22 has the time of the drill listed as "PM", with no specific time documented. The date, time, and amount of time it took to evacuate, the exit route and any issues should all be documented on the fire drill forms. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the smoke detector was operative. | The provider was retrained on fire drill documentation by the life share specialist to immediately ensure the provider understood and could abide by program expectations going forward. |
10/30/2022
| Implemented |
| 6500.121(a) | Individual #3 had an annual physical documented on 6/7/2021. The next physical was not completed until 7/24/2022 which exceeds the annual requirement. | An individual shall have a physical examination within 12 months prior to living in the home and annually thereafter. | Specialist reviewed expectations of getting physicals completed in the required amount of time. |
10/30/2022
| Implemented |
| 6500.121(c)(6) | There was no documentation provided that reflects a TB test was completed on individual #3. | Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if a tuberculin skin test is positive, an initial chest x-ray with results noted. | Specialist reviewed expectations of getting TBs completed in the required amount of time with the provider to ensure the provider is aware of regulatory standards. |
10/30/2022
| Implemented |
| 6500.121(c)(12) | Individual #3 physical dated 6/7/21 was missing the following items: Physical limitations of the individual. | The physical examination shall include: Physical limitations of the individual. | Specialist reviewed expectations of getting physicals completed in the required amount of time, and ensuring the proper information is noted on the Devereux approved physical form. |
10/30/2022
| Implemented |
| 6500.121(c)(13) | Individual #3 physical dated 6/7/21 was missing the following items: Allergies or contraindicated medications. | The physical examination shall include: Allergies or contraindicated medications. | Specialist reviewed expectations of getting physicals completed in the required amount of time, and ensuring the proper information is noted on the Devereux approved physical form. |
10/30/2022
| Implemented |
| 6500.121(c)(15) | Individual #3 physical dated 6/7/21 was missing the following items: Special instructions for the individual's diet. | The physical examination shall include: Special instructions for the individual's diet. | Specialist reviewed expectations of getting physicals completed in the required amount of time, and ensuring the proper information is noted on the Devereux approved physical form. |
10/30/2022
| Implemented |
| 6500.141 | There was an additional supply of food in the basement. There was a 3-drawer plastic style storage container which contained food. The plastic had been drooping and the drawers were not able to shut properly. In the drawers of food there was dead insects among the food supply. The food was not protected from contamination while being stored. | Food shall be protected from contamination while being stored and prepared. | A specialist reviewed with the provider the importance of storing food in safe conditions. Food was moved to an area that provided better protection from contaminants. |
10/30/2022
| Implemented |
| 6500.151(e)(4) | Individual #3 annual assessment dated 5/25/2022 did not reflect the need of supervision. | The assessment must include the following information: The individual's need for supervision. | Amendment has been made to the individual¿s current assessment to reflect the individual¿s supervision needs. |
12/09/2022
| Implemented |
| 6500.133(h) | Individual #3 had a PRN of acetaminophen 325mg which expired on 9/10/22. Expired medication shall be destroyed in a safe manner.
Individual #3 is prescribed Fluticasone Prop 50 mcg Spray. 2 sprays into each nostril daily. This medication was not on the medication administration record and the family member stated that they were not giving it to the individual as she did not need it. If a medication is discontinued, it shall be disposed of properly. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Medication was immediately discarded and reordered if needed. Specialist reviewed medication management expectations with providers and assisted in updating the medication log for the birth control. November medication logs were reviewed by the center¿s nursing department and adjusted to meet regulatory standards. |
11/01/2022
| Implemented |
| 6500.135(e) | Individual #3 is prescribed Fluticasone Prop 50 mcg Spray. 2 sprays into each nostril daily. This medication was not on the medication administration record and the family member stated that they were not giving it to the individual as she did not need it. Any changes in the prescription medication shall be made by the prescribing physician.
Individual #3 was prescribed Norg-ee which is a form of birth control which helps regulate her menstrual cycle. This medication was changed at her last gynecological apt and this medication began the first cycle at the beginning of October. The medication administration record still reflects the previous birth control prescription of Tri-femyor. The family sharer stated that she has administered the new medication Norg-ee but has intialed under the previous named medication Tri-femyor. The medication record shall be updated as soon as written notice of the change is received. | Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received. | Medication was immediately discarded and reordered if needed. Specialist reviewed medication management expectations with providers and assisted in updating the medication log for the birth control. November medication logs were reviewed by the center¿s nursing department and adjusted to meet regulatory standards. |
11/01/2022
| Implemented |
| 6500.135(g) | Individual #3 did not have psychiatric medication reviews every 3 months. The reviews provided were dated 9/13/21; 5/4/22; and 1/7/22. and 4/29/22. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review by a licensed physician at least every 3 months to document the r reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Noted reviews did not occur due to staff shortages at the contracts psychiatrist's office. Psychiatrist¿s offices provided a letter noting the reason for cancellation, and the center began working with the contracted psychiatric office to identify a new psychiatrist to reduce/eliminate the possibility of a cancelled appointment. |
10/30/2022
| Implemented |