| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | At 10:33AM, the inside of the refrigerator and freezer in the kitchen of the home contained various unsanitary conditions to include but not limited to food crumbs and particles, a frozen French fry, hair, an uncover foil pan of flour, loose flour and a black dribbles and puddles. At 10:41AM, the windowsill, of the window above the bathtub in the bathroom on the first floor of the home, had areas of stagnant water droplets, puddles and an orangish black liquid substance which appeared to be mildew and/or mold. | Clean and sanitary conditions shall be maintained in the home. | Plan of Correction:
Immediate Cleaning: On May 4, 2025, the refrigerator, freezer, and bathroom windowsill were thoroughly cleaned and disinfected using appropriate sanitizing products.
Item Removal: The uncovered pan of flour, loose food debris, and other unsanitary items were discarded.
Mold/Mildew Treatment: The windowsill area was treated with an anti-mildew solution, dried thoroughly, and sealed where needed to prevent moisture accumulation.
Staff Notification: Staff were immediately reminded of the importance of maintaining sanitation standards in both food storage and bathroom areas. |
06/11/2025
| Not Implemented |
| 6400.66 | The outside light in the rear of the home was not operable. There is not another source of light in this area. [Repeated Violation - 2/25/25, et al] | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Plan of Correction:
Immediate Repair: On May 5, 2025, the rear exterior light fixture was repaired and restored to full working condition by maintenance staff.
Functionality Test: The fixture was tested to ensure consistent illumination and functionality during evening hours.
Staff Notification: All staff were reminded to report any lighting outages immediately to prevent safety risks and ensure continuous compliance. |
06/11/2025
| Not Implemented |
| 6400.67(a) | At 10:37AM, the ventilation cover in the hallway was detached approximately one and a half inches from the wall. At 10:42AM, the ventilation cover in the vacant bedroom was detached approximately one and a half inches from the wall. | Floors, walls, ceilings and other surfaces shall be in good repair. | Plan of Correction:
Immediate Repair: On May 6, 2025, both ventilation covers were securely reattached to the wall by maintenance staff using appropriate fasteners and tools to ensure safety and stability.
Safety Inspection: A follow-up inspection confirmed that all other vent covers in the home were secure and flush to prevent similar hazards.
Staff Notification: Staff were reminded to report any loose or damaged fixtures immediately as part of routine environmental monitoring. |
06/11/2025
| Not Implemented |
| 6400.72(b) | At 10:47AM, the frame, of the screen in the window in the dining room, was bent causing three-inch gap. [Repeated Violation - 2/25/25, et al] | Screens, windows and doors shall be in good repair. | Plan of Correction:
Immediate Repair: On May 4, 2025, the damaged screen was removed and replaced with a new, properly fitting screen frame to eliminate the gap and restore functionality.
Full Window Check: All windows in the home were inspected to ensure screens were intact, secure, and free from damage.
Staff Notification: Staff were reminded to report any damage to screens, frames, or windows immediately for prompt repair. |
06/11/2025
| Not Implemented |
| 6400.101 | At 10:46AM, a black garbage bag containing discarded items that was tied to the doorknob and a laundry basket of clothes were obstructing the egress from the basement door to the outside. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Plan of Correction:
Immediate Removal: On May 5, 2025, the garbage bag and laundry basket were removed to fully clear the basement door egress. The exit path was inspected to ensure it was unobstructed and accessible.
Site Review: A walkthrough of all exit routes in the home was completed to verify that all emergency exits are free of obstructions.
Staff Notification: Staff were immediately reminded of the critical importance of keeping all egress routes unobstructed at all times, per fire safety and licensing requirements |
06/11/2025
| Not Implemented |
| 6400.105 | At 10:48AM, the dryer lint screen had an excessive accumulation of dryer lint posing a risk of combustion. [Repeated Violation - 2/25/25, et al] | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| Plan of Correction:
Immediate Cleaning: On May 5, 2025 the lint screen was thoroughly cleaned and inspected for damage. The dryer and surrounding area were also checked for residual lint buildup.
Safety Review: A review of the home's fire safety and appliance maintenance practices was conducted to ensure no additional risks were present.
Staff Notification: Staff were immediately reminded of the requirement to clean the dryer lint screen after every use and document the cleaning as part of routine household duties. |
06/11/2025
| Not Implemented |
| 6400.110(a) | At 10:42AM, there was no smoke detectors on the first floor of the home. At 10:43AM, the smoke detector in the basement was not operable. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | Plan of Correction:
Immediate Installation and Replacement: On May 5, 2025, a new smoke detector was installed on the first floor of the home, and the non-operable smoke detector in the basement was replaced with a functioning unit.
Functionality Test: All newly installed and existing smoke detectors were tested to confirm operability.
Staff Notification: Staff were informed that all smoke detectors must remain functional and in place at all required locations at all times |
06/11/2025
| Not Implemented |
| 6400.171 | At 10:34AM, a clear plastic container of strawberries with what appeared to be mold was in the refrigerator of the home. At 10:36AM, a metal pot with no lid containing cooking oil was on the stove that was not in use. According to the FDA's safe storage recommendations, used cooking oil should be strained, stored in an airtight container, and refrigerated for reuse. [Repeated Violation - 2/25/25, et al] | Food shall be protected from contamination while being stored, prepared, transported and served.
| Plan of Correction:
Immediate Removal: On May 6, 2025, the moldy strawberries and the uncovered pot of cooking oil were immediately discarded.
Appliance & Food Area Cleaning: The refrigerator and stove area were thoroughly cleaned and sanitized to eliminate any residual contamination.
Staff Notification: Staff were informed of proper food safety practices, including regular inspection of perishables and safe handling/storage of cooking oil in accordance with FDA guidelines. |
06/11/2025
| Not Implemented |
| 6400.214(b) | At 10:38AM, Individual #1's physical examinations, dental examinations, dental hygiene plans, assessments, and individual plan was not kept in the home. [Repeated Violation - 2/25/25, et al] | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| Plan of Correction:
Immediate File Update: On May 6, 2025, all required documents for Individual #1¿including physical and dental exams, dental hygiene plan, assessments, and individual plan¿were obtained and placed in the individual's personal record binder at the home.
Verification: The Program Specialist reviewed the documentation to ensure it was complete, current, and stored securely but readily accessible to staff.
Staff Notification: All staff were reminded that all required documentation must be maintained in the home and made available for review at all times. |
06/11/2025
| Not Implemented |
| 6400.163(d) | At 10:38AM, the following medications were on a shelf in the unlocked staff office: Albuterol Sulfate HFA 108mcg/act aerosol, Cydopentolate Hydrochrloride Ophthalmic Solution, and Prednisolone Acetate Op 1%. [Repeated Violation - 2/25/25, et al] | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | Plan of Correction:
Immediate Securing: On May 6, 2025, all medications were immediately removed from the shelf and placed in a locked medication storage unit in accordance with regulatory requirements.
Staff Notification: Staff were immediately informed that all medications must be securely locked at all times when not in active use and that unsecured storage is a serious violation. |
06/11/2025
| Not Implemented |
| 6400.163(g) | At 10:57AM, 1 loose Trazadone 50mg tablet was in a paper towel on top of the desk in the unlocked staff office. | Prescription medications shall be stored in an organized manner under proper conditions of sanitation, temperature, moisture and light and in accordance with the manufacturer's instructions. | Plan of Correction:
Immediate Disposal: On May 4, 2025, the loose Trazodone tablet was disposed of following the provider¿s medication disposal protocol.
Root Cause Review: Staff were questioned, and it was determined the medication was not properly administered or stored during the previous shift.
Staff Reminder: Staff were immediately reminded that medications must never be left loose, unsecured, or outside of labeled containers. |
06/11/2025
| Not Implemented |
| 6400.167(a)(1) | Trazadone 50mg, take 1 tablet by mouth at bedtime, prescribed to Individual #1 was not initialed as administered at 8:00PM on 4/30/25 at the 8:00PM. Olopatadine Hydrochloride Op 0.2% Solution with instructions to place 1 drop into both eyes daily was not initialed as administered at the 8:00AM on 4/12/25, 4/13/25, 4/15/25, 4/19/25, and 4/30/25. [Repeated Violation - 2/25/25, et al] | Medication errors include the following: Failure to administer a medication. | Plan of Correction:
Immediate Review: A medication administration review was conducted on May 5, 2025. Staff confirmed the missed documentation and, in some instances, failure to administer the medication.
Error Reporting: Medication error reports were completed for all missed doses in accordance with agency policy.
Staff Counseling: Involved staff were counseled on the severity of the documentation omissions and failure to administer medications as prescribed. |
06/11/2025
| Not Implemented |
| 6400.186 | At 10:12AM, Department licensing representatives arrived at the home. Individual #1 answered the door and said he was by himself, and he would call his staff. Direct Service Worker #1 arrived at the home at 10:27AM. In the supervision care needs of Individual #1's individual plan that was last updated on 4/25/25 reads, "[Individual #1] lives in a 1-person site and requires 24/7 supervision due to behaviors that pose as a safety concern. [Individual #1] receives residential habilitation via On-Site Companionship Services. [Individual #1] is unable to have any alone time at home or in the community due to health and safety concerns." [Repeated Violation - 2/25/25, et al] | The home shall implement the individual plan, including revisions. | Plan of Correction:
Immediate Staffing Correction: Upon discovery, Direct Service Worker #1 was instructed to report immediately to the site, and Individual #1 was confirmed safe and unharmed.
Incident Report: An internal incident report was completed, and the absence of required supervision was documented and submitted per agency and regulatory protocols.
Staff Reassignment: The responsible staff person was removed from duty pending investigation and retrained on the supervision requirements of Individual #1¿s plan.
Emergency Staffing Coverage: An emergency backup staff protocol was implemented to ensure the individual is never left without supervision again. |
06/11/2025
| Not Implemented |