| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.71 | On 2/11/2024 at 3:14pm, the cordless telephone, with access to an outside line, in the living room did not have the telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center located on or near the device. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| A list of telephone numbers including the nearest hospital, police department, fire department, ambulance and poison control center was immediately placed near the device. Phone numbers were also attached to the back of the cordless phone. [A blank "Home Inspection Checklist" that includes Emergency Numbers placed near phone and Emergency Numbers listed and readable was received on 5/20/25 and reviewed 5/29/25. DPOC by HDKP, HSLS, on 5/29/25.] |
02/11/2025
| Implemented |
| 6400.112(c) | The garage door was used as an exit during fire drills conducted on 3/13/2024, 5/4/2024, 8/21/2024, and 11/30/2024. This is not defined as a means of egress for evacuation by the Uniform Construction Code. | 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. | On 2/15/25, all management teams reviewed and were trained on site violations to include not being able to use a garage door as a means of egress for a fire evacuation. In addition, a sign was posted by the garage door to indicate that the garage should not be used as a means of egress for a fire safety evacuation drill. [Training documentation, dated 2/14/25, that addressed garage door are not egress point for emergency evacuation purposes was received on 5/20/25 and reviewed 5/29/25. DPOC by HDKP, HSLS, on 5/29/25.] |
02/15/2025
| Implemented |
| 6400.141(c)(7) | Individual #1's most recent gynecological examination was completed on 1/26/2024. This exceeds the annual requirement. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | On 3/14/ 25, The owner revised the individual's Physical Health Assessment to be more specific in the area of a gynecological exam. If no exam has been given, the doctor is now requested to give a deferred date for the exam. Individual #1 has a scheduled gynecological examination scheduled for 6/10/25. [A blank "Home Inspection Checklist" that includes individual physical examinations, including gynecological examinations, was received on 5/20/25 and reviewed 5/29/25. Training documentation, dated 2/14/25, that addressed that gynecological examinations are "logged", was received on 5/20/25 and reviewed 5/29/25. DPOC by HDKP, HSLS, on 5/29/25.] |
03/14/2025
| Implemented |
| 6400.141(c)(11) | Individual #1's medication regimen that was reviewed by the primary care practitioner during the 1/31/2025 physical examination did not include the following pro re nata medications: Senna 8.6mg, Loratadine 10mg, Polyethylene Glycol 3350 Powder, and Ibuprofen 200mg. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | The medication regimen was attached to the physical to include pro re nata medications Senna 8.6mg, Loratadine 10mg, Polyethylene Glycol 3350 powder and Ibuprofen 200mg. [A blank "Home Inspection Checklist" that includes individual physical examinations was received on 5/20/25 and reviewed 5/29/25. DPOC by HDKP, HSLS, on 5/29/25.] |
02/12/2025
| Implemented |
| 6400.151(a) | Direct Service Worker #1 had a physical examination completed on 7/2/2021, and then again on 7/31/2023. This exceeds the every 2-year 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. | On 2/14/25, managers reviewed and were trained on the Site violations including chapter 6400.151a which indicates physical examinations cannot exceed the every two-year requirement. [A blank "Home Inspection Checklist" that includes staff physical examinations was received on 5/20/25 and reviewed 5/29/25. Training documentation, dated 2/14/25, that addressed that staff physical examinations are due every 2-years was received on 5/20/25 and reviewed 5/29/25. DPOC by HDKP, HSLS, on 5/29/25.] |
02/14/2025
| Implemented |
| 6400.34(a) | Individual #1 was informed of their individual rights and the process to report a rights violation on 3/22/2023 and again on 4/20/2024. This exceeds the annual requirement. | 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. | On 2/14/25 Safe Haven management reviewed and was trained on-site inspection violations to include chapter 6400.34(a). [Training documentation, dated 2/14/25, that addressed the annual requirement of review of individual rights, was received on 5/20/25 and reviewed 5/29/25. A copy of the Delegation Chart was received on 5/20/25 and reviewed 5/29/25. DPOC by HDKP, HSLS, on 5/29/25.] |
02/14/2025
| Implemented |
| 6400.163(a) | On 2/11/2025, Melatonin 5mg tablet, prescribed to Individual #1 did not have a label issued by a pharmacy or a copy of the physician's order affixed to the medication bottle. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | On 2/12/25 a copy of the physician's order individual #1 was affixed to the over-the-counter medication bottle for Melatonin 5mg tablets. [A blank "Home Inspection Checklist" that includes medication regimes match current doctor orders was received on 5/20/25 and reviewed 5/29/25. DPOC by HDKP, HSLS, on 5/29/25.] |
02/12/2025
| Implemented |
| 6400.166(d) | Hydroxyzine Pamoate 25mg capsule, prescribed to Individual #1, indicated to "take 1 capsule by mouth three times a day (morning, midday, and bedtime) on the medication label issued by the pharmacy while the February 2025 medication administration record indicated to "take 1 capsule by mouth three times a day before outings (morning, midday, and bedtime." Polyethylene Glycol 3350 Powder, prescribed to Individual #1, indicated to dissolve the medication "in liquid" and to "increase to twice a day if no bowel movement in 3 days" on the medication label; however, these portions of the administration instructions were not included on the February 2025 medication administration record. Senna 8.6 mg capsule, prescribed to Individual #1, indicated to take "when PEG Powder/MiraLAX alone is not enough" on the medication label; however, these portions of the administration instructions were not included on the February 2025 medication administration record. | The directions of the prescriber shall be followed. | On 2/12/25 The MAR for individual #1 was revised to show the correct instructions for Hydroxyzine Pamoate 25mg, Polyethylene Glycol 3350 Powder, and Senna 8.6 mg capsule. [A blank "Home Inspection Checklist" that includes medication regimes match current doctor orders was received on 5/20/25 and reviewed 5/29/25. DPOC by HDKP, HSLS, on 5/29/25.] |
02/12/2025
| Implemented |
| 6400.182(c) | Individual #1's annual assessment was completed on 1/10/2024 for their annual Individual Support Plan meeting that was held on 8/13/2024. The assessment was not updated or reviewed within 6 months prior to the ISP meeting to ensure the information provided to the team was accurate and current. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The most current assessment for Individual #1 was completed on 1/23/25 and will be reviewed quarterly by 6/23/25 in order to remain in compliance with a scheduled ISP for 8/25. [A copy of the Delegation Chart was received on 5/20/25 and reviewed 5/29/25. DPOC by HDKP, HSLS, on 5/29/25.] |
03/15/2025
| Implemented |