| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Interviews revealed that Individual #1 had been left alone and unsupervised on 10/3/24 for approximately fifteen minutes when Direct Service Worker #3 vacated the home prior to the end of the established work hours. From 4:05PM to 4:08PM, Team Lead #2 and Direct Service Worker #3 engaged in a loud, verbal altercation that included profanity, accusations and name calling. This verbal altercation took place on the front porch of the home in the presence of Individual #1. [Repeated violation 7/23/24 et al] | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | An EIM report was filed for psychological abuse. Both staff involved were immediately removed from the site, and the incident was investigated. Staff #2 has not returned to work, and Staff #3 received additional verbal training on acceptable behavior and interactions with individuals in care. Staff #3 was reassigned to another site. |
12/16/2024
| Not Implemented |
| 6400.63(a) | At 3:16 PM, the hot water temperature measured 138.7 degrees Fahrenheit at the sink in the only bathroom in the home. | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | To address the excessive hot water temperature at the site, the maintenance team will immediately adjust the hot water heater to ensure that the water temperature does not exceed 120°F. Maintenance staff will verify that the adjustment is successful by remeasuring the water temperature at the kitchen sink and any other accessible taps. Based on a state inspector¿s recommendation, more effective thermometers (EXTECH39240) were ordered, have arrived, and are currently being distributed to all sites to enhance accuracy in temperature checks. Additionally, maintenance will inspect the hot water heater and related pipes to assess if any insulation or protective guards are needed to prevent potential contact with high temperatures. |
12/16/2024
| Not Implemented |
| 6400.64(a) | At 2:48 PM, the stovetop's four burner drip pans and the bottom of the oven's interior were blackened almost entirely with chard food particles and grease. At 3:09 PM, in Individual #1's bedroom, several large black stains of differing shapes on the carpet along the side and at the foot of their bed as well as at the bedroom's entry. Interviews revealed that the carpet stains in their bedroom were the result of food droppings. The floor vent located in Individual #1's bedroom was covered in thick layers of dust and debris. At 3:17 PM, the caulking sealing the tub to the wall in the bathroom located on the home's main level was covered with several dark spots that appeared to be mold or mildew, covering a ten-inch span along the interior corner of the tub's back end. | Clean and sanitary conditions shall be maintained in the home. | We have contracted two cleaning companies to address all cleaning-related issues, beginning on Monday, October 28, 2024. One company will perform a one-time deep cleaning of each property, while the second company will maintain a monthly cleaning schedule to ensure ongoing upkeep. Should additional cleaning needs arise, we will adjust the cleaning frequency as necessary to maintain compliance. Our Director of Residential Facilities & Compliance will conduct walkthroughs of each property alongside the new maintenance staff to assess any residential housing damages. They will develop a completion schedule for each task, specific to each house, and hold daily meetings to review progress on completed and outstanding work. The cleaning team will submit a daily checklist detailing completed and pending cleaning tasks, including scheduled dates for unfinished work. Additionally, they will document all work with before-and-after photos to verify thoroughness and quality. |
12/16/2024
| Not Implemented |
| 6400.64(e) | At 2:51 PM, the trash receptacle located in the kitchen, measuring thirty inches in height, did not have a lid or covering. [Repeated violation 7/23/24 et al] | Trash receptacles over 18 inches high shall have lids. | To address the absence of lids on trash receptacles, we are replacing existing bins without attached lids across all bathrooms, kitchens, and outdoor areas with step-on trash cans. One order was received on October 30, with additional orders expected on November 1 and 2. Residential site supervisors will verify the presence and functionality of these items during weekly inspections. |
12/16/2024
| Not Implemented |
| 6400.64(f) | At 2:24 PM, an outside trash can which was filled with garbage was located next to the front porch was open and uncovered. [Repeated violation 7/23/24 et al] | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | To address the absence of lids on trash receptacles, we are replacing all bins without attached lids across bathrooms, kitchens, and outdoor areas with step-on/hinged trash cans. Additionally, an order for outdoor trash cans with hinged lids has been placed with Home Depot to prevent insect and rodent access. Residential site supervisors will conduct weekly inspections to verify the presence and proper closure of all receptacles. |
12/16/2024
| Not Implemented |
| 6400.67(a) | At 2:52PM, the curtain rod hung above the window in the living room facing the side of the home was bent significantly with its middle sagging over the window's upper portion. At 2:55 PM, there was a hole in the kitchen wall measuring approximately twelve inches by six inches. At 3:24 PM, the wall located to the right of the door in the vacant bedroom located on the home's main level, had several areas of flaking, peeling paint, encompassing a one foot by six-inch area. At 3:17 PM, the left faucet handle located in the bathtub of the bathroom of on the home's main level was loose and separated from the wall, requiring to be pushed inward to turn on the hot water. | Floors, walls, ceilings and other surfaces shall be in good repair. | We have hired two full-time maintenance staff who will start addressing all maintenance-related issues on Monday, October 28, 2024. Their primary responsibilities include assessing all damages, promptly fixing all reported maintenance violations, and maintaining the houses to ensure they are free from any further maintenance violations. They will also train staff on completing maintenance-related issue reports and perform daily maintenance check ups at all properties. Additionally, we have appointed a new Director of Residential Facilities & Compliance, responsible for overseeing all maintenance-related violations, supporting the correction of issues, and holding the maintenance team accountable. The Director will conduct comprehensive walkthroughs of each property with the new maintenance staff to assess all residential housing damages, develop a completion schedule for each task at each house, conduct daily meetings to review completed and outstanding work, submit a daily checklist of completed and pending tasks with planned completion dates, and document all work with before-and-after photos to ensure thoroughness and accuracy. |
12/16/2024
| Not Implemented |
| 6400.72(a) | At 2:52PM, the window, facing the side of the home in the living room, did not have a screen. At 3:38PM, the only window, in the vacant bedroom on the second floor of the home, did not have a screen. [Repeated violation 7/23/2024 et al.] | Windows, including windows in doors, shall be securely screened when windows or doors are open. | We have hired two full-time maintenance staff who will start addressing all maintenance-related issues on Monday, October 28, 2024. Their primary responsibilities include assessing all damages, promptly fixing all reported maintenance violations, and maintaining the houses to ensure they are free from any further maintenance violations. They will also train staff on completing maintenance-related issue reports and perform daily maintenance check ups at all properties. Additionally, we have appointed a new Director of Residential Facilities & Compliance, responsible for overseeing all maintenance-related violations, supporting the correction of issues, and holding the maintenance team accountable. The Director will conduct comprehensive walkthroughs of each property with the new maintenance staff to assess all residential housing damages, develop a completion schedule for each task at each house, conduct daily meetings to review completed and outstanding work, submit a daily checklist of completed and pending tasks with planned completion dates, and document all work with before-and-after photos to ensure thoroughness and accuracy. |
12/16/2024
| Not Implemented |
| 6400.72(b) | At 2:58PM, the screen mesh on the kitchen screen door was disconnected from both the bottom and left side of the frame, creating a two-foot by two-foot opening. At 3:23PM, the screen in the window of the vacant bedroom on the first floor of the home, had a four inches oval-shaped tear. [Repeated violation 7/23/2024 et al.] | Screens, windows and doors shall be in good repair. | We have hired two full-time maintenance staff who will start addressing all maintenance-related issues on Monday, October 28, 2024. Their primary responsibilities include assessing all damages, promptly fixing all reported maintenance violations, and maintaining the houses to ensure they are free from any further maintenance violations. They will also train staff on completing maintenance-related issue reports and perform daily maintenance check ups at all properties. Additionally, we have appointed a new Director of Residential Facilities & Compliance, responsible for overseeing all maintenance-related violations, supporting the correction of issues, and holding the maintenance team accountable. The Director will conduct comprehensive walkthroughs of each property with the new maintenance staff to assess all residential housing damages, develop a completion schedule for each task at each house, conduct daily meetings to review completed and outstanding work, submit a daily checklist of completed and pending tasks with planned completion dates, and document all work with before-and-after photos to ensure thoroughness and accuracy. |
12/16/2024
| Not Implemented |
| 6400.82(f) | At 3:17PM, the bathroom, on the first floor of the home, did not have a trash receptacle. [Repeated violation 7/23/24 et al] | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | To address the absence of trash receptacles, as well as prevent lid separation, we are replacing existing bins without attached lids across all bathrooms, kitchens, and outdoor areas with step-on trash cans. One order was received on October 30, with additional orders expected on November 1 and 2. Additionally, an over-the-sink mirror has been ordered and will be installed by the maintenance team upon arrival. Residential site supervisors will verify the presence and functionality of these items during weekly inspections. |
12/16/2024
| Not Implemented |
| 6400.105 | At 3:31 PM, the dryer vent trap was covered in its entirety with a thick layer of dust and lint. [Repeated violation 7/23/24 et al] | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| We have contracted two cleaning companies to address all cleaning-related issues, beginning on Monday, October 28, 2024. One company will perform a one-time deep cleaning of each property, while the second company will maintain a monthly cleaning schedule to ensure ongoing upkeep. Should additional cleaning needs arise, we will adjust the cleaning frequency as necessary to maintain compliance. Our Director of Residential Facilities & Compliance will conduct walkthroughs of each property alongside the new maintenance staff to assess any residential housing damages. They will develop a completion schedule for each task, specific to each house, and hold daily meetings to review progress on completed and outstanding work. The cleaning team will submit a daily checklist detailing completed and pending cleaning tasks, including scheduled dates for unfinished work. Additionally, they will document all work with before-and-after photos to verify thoroughness and quality. |
12/16/2024
| Not Implemented |
| 6400.216(a) | At 3:28 PM, Individual #1's records that including a petty cash binder were unlocked in a closetnext to the bathroom on the first floor of the home. | An individual's records shall be kept locked when unattended.
| All personal records will be stored in a locked filing cabinet within the staff office. The pinhole privacy lock on the office door will be replaced with a secure lock. Staff will receive training on the importance of securing records immediately after use. |
12/16/2024
| Not Implemented |
| 6400.18(a)(5) | The agency did not report an allegation of neglect for failure to provide needed supervision on 10/3/24 through the Enterprise Incident Management System, the Department's information management system. [Repeated violation 7/23/24 et al] | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Neglect.
| To address the failure to report an allegation of neglect within the required 24-hour timeframe, all Direct Support Professionals, Residential Site Supervisors, and relevant staff will receive immediate retraining on proper incident reporting procedures, emphasizing the 24-hour requirement for reporting neglect allegations through the Department¿s Enterprise Incident Management System (EIM). Incident reporting logs will be monitored by designated Program¿s Department staff to ensure adherence to the reporting timeframe. |
12/16/2024
| Not Implemented |