| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(b) | At time of inspection there were several puddles or areas of standing water in the basement. A sump pump was noted at the base of the stairs however the plastic lip of the sump pump housing extended higher than the water. Additionally, the floor of the basement was stone and not leveled such to allow for proper draining to the sump pump. The standing water is a health hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | A work order was completed and maintenance expects that they will have the regrading done and will also be replacing stone in the basement by December 11th. |
12/13/2024
| Implemented |
| 6400.101 | At the time of the inspection there was a keyed deadbolt at the top of the basement stairs on the basement side, which would require a key to get out of the basement if the lock was engaged from the first floor of the home. There are no exits to the exterior of the home from the basement. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The deadbolt lock was removed and replaced with a regular door knob. |
11/20/2024
| Implemented |
| 6400.181(e)(13)(vi) | The assessment for Individual #1 dated 2/20/24 did not evaluate the progress of Individual #1 in the area of recreation over the last 365 calendar days. The section assigned for the information was blank. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | The assessments have the added information "individual's progress over the last 365 calendar days to include recreation". |
11/21/2024
| Implemented |
| 6400.181(e)(13)(vi) | The assessment for Individual #1 dated 2/20/24 did not evaluate the progress of Individual #1 in the area of recreation over the last 365 calendar days. The section assigned for the information was blank. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | The assessments have the added information "individual's progress over the last 365 calendar days to include recreation". |
11/21/2024
| Implemented |
| 6400.181(e)(13)(viii) | The assessment for Individual #1 dated 2/20/24 did not evaluate the progress of Individual #1 in the area of managing personal property over the last 365 calendar days. There was no section assigned for the required information. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | The section of managing personal property were not in the assessments. This area has been added to all assessments and the original template for everyone to use. |
11/22/2024
| Implemented |
| 6400.32(i) | At the time of inspection all of the personal care items belonging to Individual #1, #2, #3 and #4, as verified by Staff #3, were locked in the hall cabinet between the office and dining area of the home.
Individual Support Plans (ISP) for Individual #1, #2 and #3 indicate that the Individuals are not felt to be at risk in and around poisonous substances, but the substances are locked in the home. The ISP for Individual #4 indicated the need for poisons to be locked.
All personal care items belonging to Individual #1, #2, #3 and #4, as verified by Staff #3, were locked in the hall cabinet. The items included soap, shampoo, deodorant, toothpaste, toothbrushes and nonpoisonous care items.
The Individuals in the home did not have access to all of their poison safe possessions due to the items being locked. Staff #2 indicated that no restrictive plans were in place at the home.
This same row of locked cabinets, but separate cabinet, was found to house snack and food items purchased by the Individuals for their own consumption as stated by Staff #3. Some of the snack items were initialed as belonging to the Individuals. The Individuals did not have access to the snack items as the cabinet was locked with the keys maintained by staff. | An individual has the right of access to and security of the individual's possessions. | The lock was removed from the closet. All assessments and ISP's will be updated to include the specific hygiene items that the individuals are safe to use. All food was also moved to an area that is accessible. |
11/25/2024
| Implemented |
| 6400.166(a)(4) | Individual #1's Desitin, Aloe Gel, Anti Itch cream, Benadryl, Aspirin, cough drops, milk of magnesium and cough syrup were not on the November 2024 Medication Administration Record (MAR.) As per the Regulatory Compliance Guide (RCG) Over the counter (OTC) medications must be recorded on the medication record. The MAR did not include the name of the medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | All OTC's have been added to the medication log. |
11/25/2024
| Implemented |