| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(b) | The caulk on the back wall of the tub in the upstairs bathroom contained an approximate 12-inch section that was discolored with a black substance that appeared to be mold. | Floors, walls, ceilings and other surfaces shall be free of hazards. | CRHS promptly contacted the maintenance team regarding the mold concern, which was addressed the next day, 2/14/25, by recaulking the bathtub in the upstairs bathroom. Moving forward, frontline supervisors are responsible for inspecting any maintenance concerns at least weekly and reporting them to the maintenance team to ensure ongoing compliance. |
02/14/2025
| Implemented |
| 6400.72(b) | The screen in the upstairs bathroom of the home had a hole on the upper area of the screen that was approximately two inches wide. | Screens, windows and doors shall be in good repair. | CRHS promptly contacted the maintenance team regarding the window screen, which was addressed the next day, 2/14/25. The window screen was fixed and there is no longer a hole. Moving forward, frontline supervisors are responsible for inspecting any maintenance concerns at least weekly and reporting them to the maintenance team to ensure ongoing compliance. |
02/14/2025
| Implemented |
| 6400.101 | The front door of the home had a deadbolt that was keyed on both sides of the door. Keyed deadbolts on the inside of an exit door are considered to be an obstruction of egress from the home. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| CRHS promptly contacted the maintenance team regarding the deadbolt, which was addressed the next day, 2/14/25. The window screen was fixed, and there is no longer a hole. Moving forward, frontline supervisors are responsible for inspecting any maintenance concerns at least weekly and reporting them to the maintenance team to ensure ongoing compliance. |
02/14/2025
| Implemented |
| 6400.104 | The notification to the local fire department on file was dated 1/1/21. The letter indicates that the home is empty and was not updated to reflect the admission of an individual on 9/28/21 and 3/2/22. Notification to the local fire department must be kept current. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| CRHS updated and submitted all local fire department notifications for its residential sites on February 20, 2025. Moving forward, CRHS must update and submit these notifications annually or whenever there are changes to the home or the number of individuals residing there. |
02/20/2025
| Implemented |
| 6400.113(c) | Records indicate that Individual #1 received fire safety training on 10/23/24 by an outside fire safety expert. A certificate received indicated that the training encompassed training on the use of fire extinguishers. A description of the content of the training was requested to ensure that location specific topics of fire safety were also reviewed as required. The description of the content of the training was not received. | A written record of fire safety training, including the content of the training and a list of the individuals attending, shall be kept. | Individual #1 was retrained on Fire Safety by watching an OSHA Fire Safety video at her residence on Monday 2/17/25 after the Fire Safety company took time in responding on the criteria they used for Fire Safety by Expert training. |
02/17/2025
| Implemented |
| 6400.214(b) | Copies of the most recent assessment, dental, dental hygiene plan and physical were not maintained in the home as required. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| The most current copies of record information required under § 6400.213(2)-(14) were immediately provided to the residential home from the office on the same day. The individual records are securely stored in the individual's folder, which is kept locked in the residential office space or the house's locked cabinet when not in use. |
02/14/2025
| Implemented |
| 6400.46(a) | Training records indicate that Staff #1 had annual fire safety training on 10/26/23. There was no documentation that the training had been completed in 10/24 as required. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | CRHS Staff #1 underwent re-training in Fire Safety on 2/17/25 to ensure compliance, as the office could not locate his training certificate from 10/2024. |
02/17/2025
| Implemented |