| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The lower kitchen cabinets and lazy Susan have amassed dirt and grime and need cleaning. | Clean and sanitary conditions shall be maintained in the home. | WHO The Program Director is responsible for the correction of this violation
The Lazy the Suzan would be thoroughly cleaned.
The Program manager would supervise the DSP to thoroughly clean. |
03/31/2023
| Implemented |
| 6400.66 | There is no light outside of the basement door entrance/exit. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Residential Director would be responsible for fixing this violation.
A light would be installed outside of the basement door
A licensed electrician would be contracted to install a light fixture at the basement door |
04/03/2022
| Implemented |
| 6400.68(a) | The water pressure was extremely low. | A home shall have hot and cold running water under pressure. | The Residential Director is responsible.
The water pressure for the hot and cold supplies would be corrected. New faucets would be installed.
A licensed Plumber has corrected this issue. The issue was corrected on the 31st of may |
03/31/2023
| Implemented |
| 6400.111(a) | There was no fire extinguisher in the basement. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | The Residential Director is Responsible for this
A fire extinguisher would be installed in the basement immediately.
The Correction would completed immediately. The fire extinguisher was installed on the day of inspection and photographic evidence was provided to the inspection team. |
03/27/2024
| Implemented |
| 6400.112(a) | December 21st, 2023 fire drill was refused by individual 1, no additional attempt recorded. | An unannounced fire drill shall be held at least once a month. | The program specialist is responsible for ensuring a fire drill is repeated when initially refused by an individual
A fire drill would be completed within 24 hours of an individual refusing an initial attempt
Correction is Immediate. A fire drill for an individual was attempted again and the document was presented to inspectors after the inspection |
03/28/2024
| Implemented |
| 6400.112(e) | More than 6 months has elapsed since most recent overnight fire drill completed, June 23rd, 2023. | A fire drill shall be held during sleeping hours at least every 6 months. | The program specialist would be responsible for this violation
The program specialist would ensure that an overnight fire drill is completed every six months.
The overnight fire drill was completed on 4/16/2024 |
04/16/2024
| Implemented |
| 6400.141(a) | For individual 1, annual physicals were completed more than a year apart (March 2022 & December 2023). | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The Program specialist is responsible for the correction of this violation
The program specialist would ensure that every individual is scheduled for an annual physical once every 12 months.
The fix to this violation would be immediate. |
04/04/2024
| Implemented |
| 6400.141(c)(10) | For individual 1, the most recent physical doesn't answer the "free of communicable diseases" question. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | The program specialist and the Office admin would be responsible to correct this violation
Every annual physical must document the free from communicable disease question.
The fix is immediate. This particular physical did not state 'free from communicable disease' but an accompanying document came with the physical that stated 'free from communicable disease' document was presented to the inspectors on site. |
04/12/2024
| Implemented |
| 6400.141(c)(11) | For individual 1, the most recent physical doesn't answer the "assessment of the individual's health maintenance needs, etc." | 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 Program Specialist is responsible for fixing this violation.
Every annual physical would answer the assessment of the individual's health maintenance needs.
This fix would be implemented immediately. |
04/12/2024
| Implemented |
| 6400.141(c)(14) | For individual 1, the most recent physical doesn't answer the "info pertinent to diagnosis in the event of an emergency" section. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The Program Specialist, DSP, and admin are responsible for fixing this violation.
Every annual physical would document Medical information pertinent to diagnosis and treatment in case of an emergency.
This fix would be implemented immediately. |
04/12/2024
| Implemented |
| 6400.141(c)(15) | For individual 1, the most recent physical doesn't answer the "special diet instructions" section. | The physical examination shall include:Special instructions for the individual's diet. | The Program Specialist, DSP, and admin are responsible for fixing this violation.
Every annual physical would document special diet instructions
This fix would be implemented immediately. |
04/12/2024
| Implemented |
| 6400.181(a) | For individual 1, the annual assessment was completed more than a year apart, June 2022 to October 2023. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | The Program Specialist is responsible for fixing this violation.
Every annual physical would document special diet instructions.
This fix would be implemented immediately. |
04/08/2024
| Implemented |