| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | On 2/11/2025, at 1:39pm, the Microwave was observed with food splatters on inner ceiling and walls. | Clean and sanitary conditions shall be maintained in the home. | The microwave was immediately cleaned out by DSP to remain complaint. [A blank "microwave sign off sheet" was received on 5/20/2025 and reviewed 5/29/25. DPOC by HSKP, HSLS, on 5/29/25.] |
02/11/2025
| Implemented |
| 6400.68(a) | On 2/11/2025, the water temperature measured 80.4 degrees Fahrenheit in full bathroom tub at 1:42pm and 80.2 degrees Fahrenheit at 1:43pm at the sink. | A home shall have hot and cold running water under pressure. | The Program Specialist adjusted the water heater settings Immediately to increase the temperature until it reached 115°F, ensuring that the water temperature is within the appropriate range for safe and comfortable use. This is compliant with the regulation for chapter 6400.68 (a). [Blank weekly water temperature log was received on 5/20/25 and reviewed 5/29/25. A blank home inspection list that includes water temperatures was received on 5/20/25 and reviewed 5/29/25. DPOC by HDKP, HSLS, on 5/29/25.] |
02/11/2025
| Implemented |
| 6400.81(h) | On 2/11/2025, The two windows in Individual #1's bedroom were covered with a film that does not permit a view to the outside. | Each bedroom shall have at least one exterior window that permits a view of the outside. | The plastic film cover was removed immediately by PS from the windows of individual's #1 restoring an exterior view. [A blank "Home Inspection Checklist" that include windows with exterior views was received on 5/20/25 and reviewed 5/29/25. Training documentation, dated 2/14/25, that addressed that at least one bedroom window must permit a view of the outside, was received on 5/20/25 and reviewed 5/29/25. DPOC by HDKP, HSLS, on 5/29/25.] |
02/11/2025
| Implemented |
| 6400.101 | On 2/11/2025, there was a bar on the sliding door in the dining room that would obstruct egress in the event of an emergency. There was a key operated lock on the inside of the garage door and the garage door does not have another point of egress, therefore presenting an entrapment risk. There was a sliding lock on exterior side of storage room at the bottom of the basement steps presenting an entrapment risk. There was a turn/thumbnail lock on the kitchen door that leads to the basement turn lock on kitchen side and no other means egress from the basement presenting an entrapment risk. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| On 2/11/25 The bar was removed immediately from the slide to door to prevent entrapment in case of an emergency.
On 2/15/25 - sliding lock on exterior side of storage room door was removed
On 2/15/25 ¿ Key-operated lock on the door to the garage was removed and replaced with a regular doorknob. On 2/15/25 ¿ Thumbnail lock on the kitchen door turned around so the turn lock is now on the basement side, ensuring egress from the basement. [A blank "Home Inspection Checklist" that includes unobstructed egress was received on 5/20/25 and reviewed 5/29/25. DPOC by HDKP, HSLS, on 5/29/25.] |
02/15/2025
| Implemented |
| 6400.112(c) | The garage door was used as an exit during fire drills conducted on 6/15/2024, 10/8/2024, and 11/21/2024. This is not defined as an egress 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, date of admission 4/15/2024, has not had a gynecological examination completed since admission. According to testimony from agency staff, the individual has refused this form of treatment; however, no documentation of refusals or ongoing training was completed. | 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. | Individual #1 is scheduled for an annual gynecological exam on 4/8/25.
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 and / or check a box for a refusal. [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 |
| 6400.182(c) | Individual #1's annual assessment was completed on 6/10/2024 and sent to the plan team on 1/15/2025 for an Individual Support Plan (ISP) meeting scheduled for 3/4/2025. 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/ updated assessment was completed and sent to her SC on 1/15/25. However, the date was not changed to indicate the update. The date was changed immediately from 6/10/24 to 1/15/25 on 2/12/25 to indicate the correct update date and no changes in the assessment. [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.] |
02/12/2025
| Implemented |