| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Both individuals in the home are not safe with poisonous materials. There was a bottle of pledge dust spray located in a cabinet in the bathroom in the basement of the home and Colgate toothpaste in the bathrooms on the second floor of the home. Individual Service Plans do not assess the individual's ability to be safe with person hygiene items. (Repeat Violation 8/13/22) | Poisonous materials shall be kept locked or made inaccessible to individuals. | The Lift Center has removed all toothpaste from bathrooms and have locked them away. The Lift Center will ensure that all poisons are kept locked away. The Lift Center will ensure that personnel keep all closets locked and will be present at the time of licensing walk through. |
08/22/2023
| Implemented |
| 6400.67(b) | Floors are not free of hazards. The deck that connects to the first and second levels on the back of the home and around the swimming pool have significant areas of peeling paint that presents a hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The Lift Center has corrected the weathered peeled paint. The deck was stripped, sanded and repainted. |
09/03/2023
| Implemented |
| 6400.70 | The home did not have an operable noncoin-operated telephone with an outside line that was easily accessible to individuals and staff persons. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| The Lift Center has maintained an operable phone since the date of licensing 2021. Maintenance found that staff had sent a fax and forgot to disconnect the fax machine. |
08/22/2023
| Implemented |
| 6400.82(f) | Neither bathroom on the second floor of the home contained soap or individual clean paper or cloth towels. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | The staff removed all soap and paper towels as precaution to keeping all poisonous materials out of the reach of the individuals. |
08/22/2023
| Implemented |
| 6400.85(b) | The aboveground swimming pool was not made inaccessible to individuals when the pool is not in use. The pool has a gate with a lock to prevent access when not in use, however the gate was not locked at the time of the inspection. | An aboveground swimming pool that is under 4 feet in height shall be made inaccessible to individuals when the pool is not in use. | The Lift Center physically locked the locking mechanism was left unlocked for the purpose of quick accessibility at the time of inspection. |
08/22/2023
| Implemented |
| 6400.110(e) | The home has 3 or more floors. The smoke detectors in the home were not interconnected. The smoke detector in the basement of the home was not interconnected with the first and second floors of the home. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | ADT serviced the home safety and security on 8/23/2023. ADT added smoke and carbon detectors to the basement and first floor areas of the home. |
08/23/2023
| Implemented |
| 6400.112(c) | The written fire drill record for the fire drill conducted on 2/12/23 did not include the evacuation time. | 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 fire alarm or smoke detector was operative. | The Lift Center will ensure that fire drill documentation is completed in its entirety to include date, time, the amount of time it took to evacuate, the exit route. It will also include problems occurred during drill if applicable as will as smoke detector sounded during drill. |
09/11/2023
| Implemented |
| 6400.112(e) | A fire drill was not held at least every 6 months during sleeping hours. A sleeping fire drill was held on 6/7/22 and not again until 3/31/23. | A fire drill shall be held during sleeping hours at least every 6 months. | The Lift Center conducted an overnight fire drill / during sleeping hours so as to meet the requirement to conduct said drills on a biannual basis. The last overnight drill occurred in July 2023. |
08/22/2023
| Implemented |
| 6400.113(a) | Individual #1 was not trained annually 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. Individual #1 was trained in fire safety on 2/13/22 and did not receive fire safety training again until 5/23/23. | 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. | Individual #1 received fire safety training on 8/29/2022 and again on 5/23/2023. |
08/22/2023
| Implemented |
| 6400.151(a) | Staff #1 was hired on 4/12/23 and did not complete a physical examination within 12 months prior to employment. Staff #1's physical examination was not completed until 7/27/23. Staff #2 was hired on 3/20/23 and did not complete a physical examination until 4/5/23. | 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. | Staff #1 started as an intern and was hired 4/12/2023. The staff's initial physical was dated 8/15/2022 and her updated physical was conducted on 7/27/2023. The Lift Center will ensure that physicals for all staff are conducted within 12 months of hire. |
08/22/2023
| Implemented |
| 6400.181(e)(13)(i) | Individual #1's annual assessment did not include the following information: The individual's progress over the last 365 calendar days in the area of health. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health. | The Lift Center acknowledges that the Annual Assessment for CPS 2380 was wrongly filed in the 6400 book. This was rectified during licensing. |
08/22/2023
| Implemented |
| 6400.34(a) | The home did not 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. Individual #1 was informed of individual rights on 8/17/22 and had not been informed again. | 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 Lift Center will ensure that the appropriate forms are being used to informed individuals of their rights. The Lift Center will ensure that forms for CPS 2380 are not used for Residential 6400. |
08/22/2023
| Implemented |
| 6400.44(c)(2) | Staff #2, the program specialist was hired on 4/12/23 did not have 2 years of working experience with individuals with an intellectual disability or autism. | A program specialist shall have one of the following groups of qualifications: A bachelor's degree from an accredited college or university and 2 years of work experience working directly with individuals with an intellectual disability or autism. | Staff #2 was demoted to DSP/ Administrative Support immediately. |
08/22/2023
| Implemented |
| 6400.46(a) | Staff #1 did not complete fire safety prior to working with individuals. Staff #1 was hired on 4/12/23 and did not complete fire safety until 5/23/23. | Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Staff #1 received Fire Safety Training on 9/13/2022 as an Intern. |
08/22/2023
| Implemented |
| 6400.51(b)(1) | Staff #1 did not receive orientation training prior to working with individuals in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Staff #1 received previous training on Person Centered Practices, Individual Choice and supporting individuals to develop and maintain relationships 7/19/2022- 7/22/2022.
Community Integration was completed 6/22/2023. |
08/22/2023
| Implemented |
| 6400.163(h) | Prescription medications that are expired are not disposed of in a safe manner according to Federal and State statutes and regulations. Individual #1 was prescribed Albuterol HFA 90mcg, inhale 2 puffs by mouth every 6 hours as needed for wheezing. Individual #1 is prescribed Albuterol Sol 2.5mg, use vial via neb every 6 hours as needed for wheezing or short of breath. These medications expired on 8/19/23 and remained undisposed of in the home. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | The Lift Center disposed of the Albuterol HFA 90mcg, inhale 2 puffs by mouth every 6 hours as needed for wheezing.
The Albuterol Sol 2.5 mg, use vial via neb every 6 hours as needed for wheezing or short of breath. |
08/22/2023
| Implemented |
| 6400.165(c) | Individual #1's medications are not administered as prescribed. Individual #1 is prescribed Flonase, use 2 sprays into each nostril once daily at 8am. The bottle located at the home was filled on 3/9/23 and contained approximately 1/4 bottle and the bottle filled ono 5/18/23 was a full bottle that was not opened. The bottle of medication contains a 30-day supply and if administered as prescribed would need to be refilled every 30 days. The bottles dated 3/9/23 and 5/18/23 would have been completely used by the date of the inspection 8/22/23 if administered as prescribed.
Individual #1 is prescribed Head and Shoulders Classic. the label states, "apply topically to wash hair daily as needed for dandruff." the Medication Administration Record (MAR) states, "apply topically to wash hair daily" and a note from the most recent appointment with the prescribing physician states "please use head and shoulders OTC shampoo daily for dandruff." The MAR is documented with the medication being used as needed and not daily. the medication is not being administered as prescribed. | A prescription medication shall be administered as prescribed. | The Lift Center contacted Newhardt Pharmacy at the time of licensing.
Flonase, use 2 sprays into each nostril once daily at 8am was reordered and will be administered as prescribed.
The Lift Center was sent Head and Shoulders shampoo labels to match the doctor's order to administer daily at 8:00am |
08/29/2023
| Implemented |
| 6400.207(4)(II) | A chemical restraint, Lorazepam for the specific and exclusive purpose of controlling acute and episodic aggressive behavior. Individual #1 is prescribed Lorazepam I1mg, take 1 tablet by mouth 3 times daily as needed for anxiety. There is not protocol available to identify when this medication should be administered. Staff administered the medication on 8/8/23 at 8pm. | A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Pretreatment prior to a medical or dental examination or treatment. | The Lift Center obtained a protocol of when to administer the PRN Lorazepam 1mg which is generic for Ativan. |
09/13/2023
| Implemented |