| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | There were poisons found unlocked in the upstairs bathroom of the home. A spray bottle of Clorox Cleanup was laying out in plain sight in the bathroom and other cleaning products were in an unlocked cabinet. Both the ISP and the annual assessment for the individual living in the home state that poisons are required to be locked. Staff working in the home on the date of the inspection told the licensing representative that the individual living in the home was unable to navigate the steps. However, the ISP states that the individual can navigate uneven terrain and stairs with minimal difficulty. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The LIFE GROUP will ensure that poisonous materials are locked and made inaccessible to the individuals. The poisons from upstairs were removed and locked in the cabinet with the other poisons in the office. Staff will be retrained this month on the safety section of the ISP as it relates to poisons. |
10/17/2024
| Implemented |
| 6400.64(a) | There was significant grease and dirt buildup inside the oven door and on the bottom of the oven that requires cleaning | Clean and sanitary conditions shall be maintained in the home. | The LIFEGROUP will ensure clean and sanitary conditions will be maintained throughout the home. The oven was cleaned inside and out to remove the grease and dirt buildup that was noted by the auditor. |
11/01/2024
| Implemented |
| 6400.72(b) | The back door leading from the kitchen to the outside of the home has a screen door where the screen is torn at the bottom and requires repair or replacement. Repeat violation | Screens, windows and doors shall be in good repair. | The LIFEGROUP shall ensure that screens, windows, and doors shall be in good condition and repair. The storm door was replaced with a new fully functioning door. |
11/01/2024
| Implemented |
| 6400.112(a) | The ISP and annual assessment for Individual #1 both state that the individual benefits from warnings prior to the fire alarm sounding in the home. While completing the unannounced inspection, the staff at the home indicated that it would be problematic if the individual would be asked to leave the home when testing the alarm. A review of the past year of completed fire drill forms did not indicate either prior warning before the drills nor did they indicate that there were problems during the drills, including during the sleep-time drills, where only one staff was present. Based on the information in the assessment and the ISP, and the interview with staff on the date of the unannounced inspection, the fire drills being completed in the home are not unannounced as required by regulation and are not an accurate reflection of the time necessary to evacuate the residence.
Repeat Violation. | An unannounced fire drill shall be held at least once a month. | The LIFE GROUP will ensure that unannounced fire drills will be held once monthly. The November fire drill was an unannounced drill that was conducted by the Program Manager. |
11/08/2024
| Implemented |
| 6400.144 | Individual #1 is prescribed SF 5000 Plus prescription toothpaste. The prescription label states to apply to teeth when brushing teeth twice daily for dental care. It is also written in the narrative space on the MAR exactly the same way. However, it is listed on the MAR as a PRN and staff are only initialing once daily that the prescription toothpaste is being administered for toothbrushing. In addition, no initials at all were on the MAR for administering the prescription toothpaste on 10/11/24 or 10/14/24.
Repeat Violation | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| The LIFE GROUP shall ensure that all health services, medical, pharmaceutical, dental, dietary, and psychological are planned for and provided. The correction involved having the pharmacy correcting the MAR to include it as a scheduled med instead of a PRN medication. |
11/01/2024
| Implemented |
| 6400.181(f) | The annual assessment for individual #1 was written and copied to the individual's team on 7/1/24. The ISP meeting for the individual was held on 7/18/24. This does not meet the regulation which requires the program specialist to provide the assessment to the team at least 30 days prior to the ISP meeting.
Repeat Violation | 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 LIFE GROUP shall ensure the PS provides the annual assessment to the team members 30-dayss prior to the ISP meeting. The newly appointed PS has created a document to indicate when the annual assessments are due. to ensure the assessments are sent to the team 30 days before the ISP meeting timeframe. |
11/04/2024
| Implemented |