| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | On 10/29/2024, the agency's self-assessment of the home, end dated 10/1/2024, did not address the following 6400 regulations, as they were left blank: 18j6, 19a1 under General Requirements; 31e through and including 34b under Individual Rights; 42 through and including 52c6 under Staffing; 61a through and including 86 under Physical Site; 101 through and including 114b under Fire Safety; 141a through and including 145(3) under Individuals Health; 151a through and including 152c under Staff Health; 161a through and including 169d under Medications; 171 through and including 176 under Nutrition; 181a through and including 181f under Assessments; 182a through and including 209 under Plan Development/Process/Content, 188a through and including 188d under Home Services; 189a through and including 190c under Day Services/Recreational and Social Activities; 191 through and including 208e under Restrictive Procedures; 211a through and including 217 under Individuals Records; 231 through and including 245d under Nine or More Individuals; 261a through and including 263 under Respite Care; 271(1) through and including 275 under Semi-Independent Living. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| The Director of Programs will complete the self - assessment on the ODP approved agency form only. The self - assessment will be completed between June and September which is 3-6 months prior to the expiration of the certificate of compliance. Areas of non - compliance will be addressed by the Director of Programs. Calendar reminders have been set for 2025. |
11/01/2024
| Implemented |
| 6400.67(a) | On 10/30/24 at 11:07AM, the dining room flooring was chipped off in an approximate section of 4 inches by 1 inches near the floor vent, creating a potential tripping hazard. | Floors, walls, ceilings and other surfaces shall be in good repair. | The home was under renovation and new flooring was placed in the kitchen and dining room on November 5, 2024 by a licensed contractor. |
11/05/2024
| Implemented |
| 6400.76(a) | On 10/30/24 at 10:52AM, the inside of the microwave in the kitchen was delaminating and missing the ceramic protective coating. | Furniture and equipment shall be nonhazardous, clean and sturdy. | On 10/31/24 the director of programs purchased a new microwave and discarded the old microwave. |
10/31/2024
| Implemented |
| 6400.101 | On 10/30/24 at 11:06AM, the basement door leading from the garage contained a dead bolt lock and also a chain latch lock. [Repeat Violation 11/14/23, et. al.] | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The deadbolt was removed from the door on 10/31/2024, by the agency maintenance provider. |
10/31/2024
| Implemented |
| 6400.110(e) | On 10/30/24 at 11:06AM, the smoke detectors on all 3 floors were operable; however, the smoke detectors were not interconnected. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | On 11/1/2024 new interconnected smoke detectors were installed by agency maintenance. |
11/01/2024
| Implemented |