| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | At the time of the inspection, there was no lighting at all in the hallway in the basement leading from the common area to the bathroom. Staff #1 noted during the inspection that Individual #1 does utilize the basement including the common area. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The Director of Maintenance was asked on 8/14/2024, to install a light in the hallway to the downstairs bathroom. When the light is installed, pictures and video will be sent to the Licensing Supervisor, KCS. |
08/14/2024
| Implemented |
| 6400.104 | A notification letter was sent on 1/5/24 to the local fire department, however Individual #1 moved into the home on 7/1/24, and an updated letter was not sent out to the fire department with this notification. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| A new letter was updated and sent to the fire department with the required mobility information of the individuals as well as the total capacity of the dwelling. |
08/20/2024
| Implemented |
| 6400.113(a) | Individual #1's date of admission is 7/1/24, and their fire safety training was completed on 7/5/24. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | The Program Specialist will ensure that initial mandatory training is done on the date of admission. |
08/15/2024
| Implemented |
| 6400.151(a) | A staff person who shall have a physical examination within 12 months prior to employment. Staff #1's date of hire is 5/27/24, and their physical examination was dated 6/1/24. This exceeds the requirement. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | The Program Specialist will make sure that physical for new hires is received prior to a start date being assigned. |
08/15/2024
| Implemented |
| 6400.34(a) | Individual #1's date of admission is 7/1/24 and they weren't informed of their Individual rights until 7/5/24 when the document was signed by Individual #1. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | The Program Specialist will ensure that initial mandatory training is done on the date of admission. |
08/15/2024
| Implemented |
| 6400.196(a) | Individual #I has a behavior support plan (BSP) which is dated 7/3/24. Staff working in Individual #1's home implement and manage a behavior component of Individual #1's individual plan. Staff working in Individual #1's home are not trained in the use of the specific techniques or procedures that are used as the BSP signature sheet attached to the BSP for Individual #1' that was in Individual #1's file to document the staff were trained on the BSP was blank containing no staff signatures. | A staff person who implements or manages a behavior support component of an individual plan shall be trained in the use of the specific techniques or procedures that are used. | Regardless of how BSPs come to us we will ensure that all staff and agency representatives are properly trained before working with the individuals. |
08/16/2024
| Implemented |