| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | There was no light on the outside back the home. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| A outdoor light was installed at the back of the home on 10/10/24. |
10/10/2024
| Implemented |
| 6400.110(a) | Although the fire alarm in the Livingroom area was audible throughout the home when set, the basement and bedroom (upstairs) alarms did not operate at the time of the inspection. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | The living room smoke alarm was repaired on 10/10/24. All of the smoke alarms in the home are operable and interconnected. |
10/10/2024
| Implemented |
| 6400.151(b) | Visit Summary on file for staff one dated 5/7/24, but we need the actual completed physical signed by physician. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | HR has identified the issue of physical examination compliance and has designed a written plan of correction to prevent an oversight of this nature from occurring in the future. |
10/11/2024
| Implemented |
| 6400.46(b) | Youtube video was used to train staff one. The video was by a company called Fire Safety Compliance LLC. No source was provided to demonstrate that the company or person in the video met any of the following qualifications:
It is the provider's responsibility to demonstrate that this training was provided by a qualified fire safety expert; a safety expert must be one of the following:
· Member of a local fire department,
· Fire protection engineer,
· State-certified fire protection instructor,
· College instructor in fire science,
· Graduate of a county or State fire school,
· Volunteer trained and certified by a county or Commonwealth fire school; or
· Insurance company loss control representative. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | All staff will now be trained on fire safety through Relias. Relias is accredited through the National Alliance of Direct Support Professionals (NADSP). God's Glory will also include Fire Training via Relias specifically for on-site training as well. |
10/10/2024
| Implemented |
| 6400.181(f) | In Individual One's binder, inspector was unable to locate notification from Program Specialist to team that annual assessment was sent at least 30 days prior to Individual Plan meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The 30-day annual assessment has been revised and implemented as of our first post-licensing assessment for 10/17/24. |
10/17/2024
| Implemented |
| 6400.183(c) | Inspector was unable to locate list of persons who participated in Individual One's ISP Meeting. | The list of persons who participated in the individual plan meeting shall be kept. | This individual's ISP meeting was held virtually, and we were unable to get a sign-in sheet from the SCO. Therefore, God's Glory created its own sign-in sheet, which will be used for all future ISP meetings. |
10/14/2024
| Implemented |