| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | At the time of inspection, the flood lights in the rear of the home could not be made to function. There was no other lighting in the rear of the home to provide illumination during darkened conditions. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Provider has contacted electrician and will be installing a new light in the rear of the home. Light will provide better illumination for staff and clients. Staff will monitor this light to make sure it is in good working order at all times. |
10/05/2025
| Implemented |
| 6400.112(e) | The two most recent fire drills held at this location during sleeping hours took place on 10/28/2024 and 08/26/2025. A fire drill was not held during sleeping hours at least once every 6 months at this location as required. | A fire drill shall be held during sleeping hours at least every 6 months. | Program Manager's and DSP's will be retrained on fire safety and fire drill requirements under Chapter 6400.112 (e). Program Managers will review all fire drill records and provide individual feedback to employees of missing or incorrect data. IHRS's Quality Assurance and Regulatory Compliance Manager will be responsible to collect and review all sites fire drill records on a monthly basis. Quality Assurance Manager will provide monthly updates to Program Managers on when required sleep drills are to take place in addition to their individual tracking of such. |
10/05/2025
| Implemented |
| 6400.112(h) | The fire drills for this location did not note whether all of the individuals residing in the home evacuated to the designated meeting area outside of the home. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | Program Manager's and DSP's will be retrained on fire safety and fire drill requirements under Chapter 6400.112 (h). Program Managers will review all fire drill records and provide individual feedback to employees of missing or incorrect data. IHRS's Quality Assurance and Regulatory Compliance Manager will be responsible to collect and review all sites fire drill records on a monthly basis. All employees and consumers will be trained on meeting places for their respective sites. |
10/05/2025
| Implemented |
| 6400.141(a) | Individual #2 was placed at the provider's program on 04/16/2025 through emergency respite and was considered to be admitted to the program effective 31 calendar days later, on 05/17/2025. There was no record of a physical examination being completed for this individual within 12 months prior to the individual's admission to the home on 05/17/2025. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Physical has been completed and received. Physical was completed within proper timeframe but was not available at the time of licensing. Program Managers, Quality Assurance Supervisor and nursing staff will be retrained on the requirements needed for 6400. 141 (a). This requirement will be added to the new admission intake checklist in an effort to ensure the regulation is met. Admission Intake packet has just been implemented as a requirement of Performance Based Contracting and will serve as an additional tool in compliance tracking. |
10/05/2025
| Implemented |
| 6400.141(c)(6) | Individual #2 was placed at the provider's program on 04/16/2025 through emergency respite and was considered to be admitted to the program effective 31 calendar days later, on 05/17/2025. There was no record of tuberculin testing with a negative result being completed for this individual within 12 months prior to the individual's 05/17/2025 admission to the home. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | TB has been completed and received. TB was completed within proper timeframe but was not available at the time of licensing. Program Managers, Quality Assurance Supervisor and nursing staff will be retrained on the requirements needed for 6400. 141 (c) (6). This requirement will be added to the new admission intake checklist in an effort to ensure the regulation is met. Admission Intake packet has just been implemented as a requirement of Performance Based Contracting and will serve as an additional tool in compliance tracking. |
10/05/2025
| Implemented |
| 6400.181(a) | Individual #2 was placed at the provider's program on 04/16/2025 through emergency respite and was considered to be admitted to the program effective 31 calendar days later, on 05/17/2025. The initial individual assessment for this individual was not completed until 08/27/2025, more than 60 calendar days after the individual's 05/17/2025 date of admission to the provider's program. The initial individual assessment was not completed within 1 year prior to or 60 calendar days after admission to the residential home as required. | 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. | Program Managers, Quality Assurance Supervisor and direct support professionals will be retrained on the requirements needed for 6400. 181 (a). This requirement will be added to the new admission intake checklist in an effort to ensure the regulation is met. Admission Intake packet has just been implemented as a requirement of Performance Based Contracting and will serve as an additional tool in compliance tracking. |
10/05/2025
| Implemented |
| 6400.163(d) | All three of the home's residents---Individual #2, Individual #3, and Individual #4---were assessed as being self-medicating. At the time of inspection, each of the three individuals' prescription medications were stored in a locked cabinet in the home's staff office. The key to the cabinet was hanging on a hook near a desk in the same room. It was reported that each individual was aware of the location of the key and used it to access the cabinet to administer their own medications independently at their medication administration times. According to the Chapter 6400 Regulatory Compliance Guide (RCG), revised 03/15/2023, a primary benefit of this regulation is to prevent unauthorized access to medications. Although the individuals were trusted by the provider to access only their own medications, each had de facto unauthorized access to the medications belonging to the other two individuals. As the lock on the cabinet posed no obstacle to an individual who wished to access medications that were not prescribed to them at any point in time, it was not serving its primary benefit as intended and was, effectively, unlocked with respect to the intent of this regulation. Individual who self-medicate may store their medications in their private bedroom or with their personal belongings. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | All medications were moved to private secure locations in the home. Each resident has access to their medication and their medication only. Staff has access to all medications in the event of emergency of for routine checks. Staff access will be kept away from other residents. |
10/05/2025
| Implemented |