| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 20.34 | OPD was unsuccessful at obtaining current MAR for the month of November for individual 1. ODP was only provided the medication administration record for the month of October which was not current for the current unannounced monitoring. | The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients. | On 11/25/24, Medication Technician was contacted and informed staff where MAR's was located, in the office. Medication Technician that was at the site placed the MAR's back in the medication box. The program secured individual #1 MAR in the locked box that also has a combination lock on it.
11/25/24, the inspector was provided with a copy individual's #1 November 2024 medication administration record.
11/26/25, CEO provided Medication Technician, Nurse, Program Specialist with brand new combination locks. Medication Technician along with DSP will be present when ad mistering medication to assure that individual 1 temperament is not destructive before pulling the MAR sheet out of the box.
12/12/24 The new lock combination will allow ODP, SC to have a temp code in order to gain immediate access to medication and MAR sheet at all times. Combinations locks were placed on the medication boxes |
11/25/2024
| Implemented |
| 6400.63(a) | Bathroom bathmat in bathroom 1 has black substance in bottom consist with dirt and/or mold | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | The house supervisor and DSPs on shift failed to clean the bathroom mat located in the bathroom as a part of their everyday work practices.
11/25/24, the house supervisor replaced the slip resistant bath mat in the bathroom.
The house supervisor and DSPs were reeducated on the checking the home for cleanliness and using the daily cleaning checklist as part of their everyday job assignment. |
11/25/2024
| Implemented |
| 6400.64(a) | There were several areas in the residence where ether were cleanliness issues. Those areas are as follows:
Individual 1 room was extremely cluttered. They state that they often throws their clothes about and likes to leave them all over the bedroom floor.
The basement was extremely cluttered and difficult to maneuver through.
The oven interior was soiled with burnt food.
All appliances (including but not limited to the air fryer, inoperable ice maker and microwave) found upon countertops in kitchen were unclean | Clean and sanitary conditions shall be maintained in the home. | The house supervisor and DSPs failed to ensure that the home was being cleaned as a part of their every day work practices.
On 11/25/24, the house supervisor and DSPs staff assisted individual #1 with cleaning their bedroom. The DSP staff completed a thorough cleaning of the kitchen to the stove, air fryer and countertops in the kitchen. The inoperable icemaker and microwave was disposed of from the home. The CEO follow up with the maintenance contractors to remove the clutter in the basement.
On 12/2/24, the basement was cleaned out and exterminated by the maintenance contractors. |
12/12/2024
| Implemented |
| 6400.64(a) | The basement appears to be a dumping ground for many items in the home. Furniture, games, other household items were stored in the basement in an unorganized manner which made the basement very cluttered with minimal walkway space. | Clean and sanitary conditions shall be maintained in the home. | On 11/25/24 individual 1 was relocated to another home until repairs are completed.
On 11/25/24, the CEO contacted the maintenance contractor to clean out entire basement.
11/26/24: Staff was retrained on maintaining a clean and clutter free environment.
12/2/24, the basement area was cleaned out by the maintenance contractor.
12/10/24: home was temporary closed until renovation are completed.
1/3/2025 Basement will be fully renovated and remodeled. |
12/02/2024
| Implemented |
| 6400.64(b) | Residence shows significant signs of rodent infestation including but not limited to mice, flies and roaches/ants. Fly traps hung from ceiling covered with dead flies. Glue boards were present in lower cabinets. Upper cabinets showed signs of mice eating at stored food. Food storage located in basement had significant amounts of mice droppings around all food/drinks. While inspecting the bathroom, Inspector witnessed a bug crawling along the shower wall. | There may not be evidence of infestation of insects or rodents in the home. | The house supervisor failed to schedule routine pest control service for the home. The house supervisor did not alert the CEO or maintanence department of concerns of rodent and bug infestation throughout the home.
11/25/24, the CEO contacted the maintenance department to provide pest control service to treatment the rodent and bug infestation in the home. The house supervisor removed the fly trap from the ceiling. The glueboards were removed from the lower cabinets. The kitchen cabinets was sanitized and cleaned out by the DSP staff. The food in the basement was disposed of in the garabage. The bathroom was sanitized and cleaned by staff. |
12/02/2024
| Implemented |
| 6400.64(f) | Trash left outside of the home in bags and not in cans | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | The house supervisor and DSPs on shift failed to ensure that the trash was disposed of properly in the trashcan outside of the home.
On 11/25/24, the DSP staff disposed of the bags of trash in the trash can outside of the home. |
12/09/2024
| Implemented |
| 6400.67(a) | There were areas of disrepair in the residence that are in need of repair. Those areas are as follows:
There were several holes in the walls throughout the home; some poorly patched and other full exposed and unaddressed. | Floors, walls, ceilings and other surfaces shall be in good repair. | The CEO failed to ensure the timely completion of the repairs for the holes in the wall by the contractor.
Prior to the inspection the CEO had contracted with a home improvement company to fix the walls in the home. On 11/25/24, the CEO followed up with the contractor on repairs for the holes in the walls throughout the home. On 12/2/24, the contractor continued repairing the holes in the walls. |
12/12/2024
| Implemented |
| 6400.72(a) | The front bedroom contains three windows; two of which were completely inoperable as covered by a full sheet of plexiglass. The third window was unlocked, opens fully and does not have any screens to prevent falls/injuries. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | The house supervisor and DSPs failed to ensure the window in the home were operable with screens.
On 12/5/24, the CEO submitted a work order for the front bedroom windows to be fixed and to put in new window screens. |
12/12/2024
| Implemented |
| 6400.72(b) | The door to the closet found in Individual 1 room was off its hinges. | Screens, windows and doors shall be in good repair. | The house supervisor and DSPs failed to ensure individual #1 closet door was hung properly.
11/25/24, the CEO submitted a work order to have individual #1's closet door put back on the hinges. On 12/5/24, individual #1 bedroom closet door was rehung properly. |
12/09/2024
| Implemented |
| 6400.73(b) | The railing leading into the home was detached from exterior wall presenting as an extreme hazard and safety concern. Staff Member Leah Briggs stated that a work order was completed but was unable to provide. | Each porch that has over an 18-inch drop shall have a well-secured railing. | The house supervisor failed to follow up on the timely repair of the exterior handrail.
Prior to the inspection Martha's Way contracted with a home improvement contractor to fix the hand rail. 11/25/24, the CEO followed up with the home improvement contractors on the status of the repair of the exterior handrail.
11/25/24 Individual 1 moved to another location immediately.
On 12./5/24, the handrail was reattached and secure to the exterior wall. The contractor completed a check of all interior and exterior handrails for safety,
12/10/24, contractor informed CEO that railing needs to be taken down completely and have a welder reattached. Will be completed by 12/31/24
12/10/24, site temporarily closed until repair is completely done. |
12/09/2024
| Implemented |
| 6400.81(k)(2) | Individual 1 bedframe was not securely attached and wobbled considerably and could potentially result in injury. | In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. | The house supervisor and DSPs failed to submit a work order for individual #1 bed frame.
11/25/24, the CEO placed a work order to tighten the screws and bedrails for individual #1 bed. |
12/09/2024
| Implemented |
| 6400.81(k)(3) | There was no linen/bedding on Individual 1 bed (sheets, pillowcases and/or blankets). | In bedrooms, each individual shall have the following: Bedding, including pillow, linens and blankets appropriate for the season. | The DSP on shift failed to make individual#1 bed as the individual favorite bed linen was being washed that morning.
11/25/24, the DSP placed individual #1 favorite bed linen back on her bed. |
12/09/2024
| Implemented |
| 6400.101 | Approximately 6.5-foot ladder was left in the basement entryway creating a blockage when attempting to enter or exist the basement | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The home improvement contractors failed to put back the ladder in the basement which they left in the basement entryway.
11/25/24, the house supervisor removed the ladder from basement entryway. |
12/09/2024
| Implemented |
| 6400.111(f) | All fire extinguishers in home had not been inspected since May 2023. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | 12/12/24, 3 Fire extinguishers were purchased and placed on all three floors of the home. |
12/12/2024
| Implemented |
| 6400.163(a) | Three loose pills for individual 1 Oxcarbazepin 600 mg was left inside of the medication bin and not in its correct blister package | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | The med tech failed to ensure all medication were secured, sealed and/or properly discontinued in individual #1s med box.
12/5/24 the med tech completed a search of individual #1 medication box for any loose pills not in its original container. The med tech was unable to locate any loose pills in individual #1 medication box for proper disposal. |
12/09/2024
| Implemented |
| 6400.163(d) | Over the counter Benadryl medication was left open in staff area in an opened desk drawer visible and accessible to anyone who entered the room. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | The DSPs and Med Tech failed to properly secure and locked the Benadryl medication in the staff office.
On 11/25/24, the DSP staff on duty secured the Benadryl medication. |
12/09/2024
| Implemented |
| 6400.165(c) | In the presence of ODP investigators, Individual 1 stated that she did not take her medication this morning. Staff did not dispute with her statement. Individual 1 stated no one came to give her medication this morning. ODP unable to verify this statement as no MAR was provided for November 2024 | A prescription medication shall be administered as prescribed. | The house supervisor wasn't present at the time of individual's #1 medication administration in which she couldn't verify if the individual had taken her 8:00am medications.
On 11/25/24, individual #1 refused her morning 8:00am medications. Martha's Way med tech confirmed that individual #1 was offered her morning medications in which she refused to take them. Individual #1 MAR is kept in locked closet in the staff office. The inspector was provided with indidividual #1 November 2024 for review. |
12/09/2024
| Implemented |