| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | The portion of the basement towards the front of the home was not able to be lit during the inspection. One small "coal room" and one larger storage area had lighting fixtures present; however, these fixtures could not be turned on despite repeated attempts by provider staff. Even though lighting was present in attached areas of the basement, the front portion remained very dark, and visibility remained poor. These poor lighting conditions in the front portion of the basement could result in accident or injury. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Fixture bulbs were replaced and staff instructed on location of light switch. |
02/14/2023
| Implemented |
| 6400.67(a) | A large section of pink fiberglass insulation---approximately 5 feet in length---was hanging loosely from the basement ceiling. A chunk of the same type of insulation---approximately 2 feet in length---was lying on the basement floor below the dangling portion, suggesting it had become dislodged from the ceiling and fallen onto the floor. The insulation affixed to the basement ceiling is not in good repair. | Floors, walls, ceilings and other surfaces shall be in good repair. | Facilities Maintenance removed old insulation, cleaned area, replaced and secured new insulation. |
02/14/2023
| Implemented |
| 6400.67(b) | At the time of inspection, there was a golf-ball-sized collection of lint in the dryer lint trap. The collection of lint in the dryer lint trap creates an increased risk of fire within the home. The stairs leading down into the home's basement were coated with a significant amount of what appeared to be a mixture of dust and crushed chunks of chipped-off paint and plaster that had come loose from the walls of the stairwell over a long period of time. This detritus, which was sand-like and gritty, could easily cause a person traversing the stairs to slip and fall. Detritus of the same appearance and texture also coated several areas of the floor throughout the home's basement. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The dryer lint was removed from the dryer lint trap immediately upon discovery. The basement was swept and cleared of detritus on 2/11/2023. |
02/11/2023
| Implemented |
| 6400.81(k)(6) | Individual #2's bedroom did not contain a mirror. During the inspection, provider staff asserted that this was due to behavioral concerns and was outlined as an intervention in the individual's Individual Support Plan (ISP); however, the ISP did not contain a statement relating to the allowable absence of a mirror in the individual's bedroom. | In bedrooms, each individual shall have the following: A mirror. | An IDT Meeting was held on 2/8/2023 and the concern of individual #2 having an allowable absence of a mirror was discussed. An update was made to the ISP and verified on 2/20/2023 to indicate Individual #2 does not need a mirror in his room due to behavioral concerns was added. |
02/20/2023
| Implemented |