| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | Two of the knobs on the clothes dryer were missing. | Floors, walls, ceilings and other surfaces shall be in good repair. | CEO ordered the knobs. |
10/10/2023
| Implemented |
| 6400.101 | The area around the rear door was obstructed and being used as a storage space. This area was cleared out during the inspection. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Area was cleared out by CEO. |
10/10/2023
| Implemented |
| 6400.110(e) | The smoke detectors in the home were functional however they were not inter-connected, and the home has 3 stories including the attic. | 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. | The Director or operations sealed the attic removing access and the third level. |
10/10/2023
| Implemented |
| 6400.112(a) | There was no documentation that fire drills were completed in October + November of 2022 at this location. | An unannounced fire drill shall be held at least once a month. | The Director will re-train Operations Team on regulation 6400.112(a) as it pertains to the completion of monthly drills and record keeping. Training will also include a review of the Fire Drill Record form and the submission process. Operations staff will submit all completed fire drills on the Fire Drill Record form via paper. The Director will monitor to ensure they are completed and scanned into SharePoint (electronic record storage). |
10/09/2023
| Implemented |
| 6400.141(c)(14) | Individual#1s annual physical examination did not include information pertaining to diagnosis in case of emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Individual #1's physician was contacted to provide information pertinent to treatment and diagnosis. |
10/09/2023
| Implemented |
| 6400.32(s) | The backdoor leads to a room which is shut off from the rest of the home with a keypad. | An individual has the right to have a key, access card, keypad code or other entry mechanism to lock and unlock an entrance door of the home. | The CEO removed the keypad. |
10/10/2023
| Implemented |
| 6400.165(b) | Individual#1 is prescribed Vitamin D 1000 U tabs to be taken at 8am daily. The blister pack and MAR state that 2 tablets should be taken however one was present in the blister pack. | A prescription order shall be kept current. | Individual #1 's Vitamin D order was confirmed to be 1 pill as packed in the blister pack. The pharmacy was contacted and corrected the label and the MAR was updated. |
10/09/2023
| Implemented |