| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | At the time of the inspection, the kitchen chairs had tears in the seat and along the tops of each of the chairs. | Floors, walls, ceilings and other surfaces shall be in good repair. | The kitchen chairs in the home will be replaced by 10/31/2024. |
10/31/2024
| Implemented |
| 6400.76(a) | At the time of the inspection, Individual #2's reclining chair in the living room that is made with artificial leather was torn in multiple places on the top of the left side arm & the right lower side closest to the seat of the chair. The tears caused sharp edges that could be hazardous to the Individual. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Individual #2 has begun shopping for a new chair. A cover has been placed on the current chair to protect from rough edges until the new chair can be delivered. |
10/31/2024
| Implemented |
| 6400.141(c)(12) | Individual #1's physical completed on 7/22/24 did not document the individual's physical limitations. The section was left blank. An email was sent for clarification to the doctor on 8/29/24. | The physical examination shall include: Physical limitations of the individual. | The house manager for individual #1's home has been re-trained in the requirements for an annual physical. |
10/10/2024
| Implemented |
| 6400.141(c)(15) | Individual #1's physical completed on 7/22/24 did not document the individual's special instructions for their diet. The section was left blank. An email was sent for clarification to the doctor on 8/29/24. | The physical examination shall include:Special instructions for the individual's diet. | The house manager for individual #1's home has been re-trained in the requirements for an annual physical. |
10/10/2024
| Implemented |
| 6400.151(a) | Staff #4's physical exam was completed on 6/22/22 and not again until 6/24/24, outside of the required timeframe. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | The Admin assistant will adjust staff physical due dates back 1 month, asking them to be completed every 11 months to ensure the required timeframe is met. |
10/04/2024
| Implemented |
| 6400.151(b) | The physical exam for staff #3 was not dated by the physician. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | The Admin assistant will send staff #3's physical to the provider to request a signature on the form. |
10/04/2024
| Implemented |
| 6400.24 | Staff #3 worked in the home with Individuals on 7/2/24 when there was no documented criminal history check completed until 7/2/24 which came back with a criminal record. The criminal record history record was not obtained until 7/9/24. There was no documentation that the provider had a discussion regarding the criteria required when a staff member has a criminal history: · The nature of the crime,
· Facts surrounding the conviction,
· Time elapsed since the conviction,
· The evidence of the individual's rehabilitation; and
· The nature and requirements of the job. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | Applicants will not being working with individuals until their criminal background check is received and reviewed. Applicants with criminal backgrounds will review their record with management prior to having contact with individuals. Management will determine if the staff is eligible for hire based on the nature of the record, how long it has been since the criminal offenses occurred, if the record will affect the staff's ability to perform the duties of the job they are being hired for, and if their is evidence that the staff has been rehabilitated. |
10/04/2024
| Implemented |
| 6400.34(a) | Individual #1 were not informed of the following rights: 31a through 31g and 33a and b on 1/1/24. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | The individual rights forms have been updated to include 31a through 31g and 33a and b. The updated individual rights forms have been signed and will be on file in individual #1's permanent record and reviewed with all individuals in care. |
10/04/2024
| Implemented |
| 6400.213(1)(i) | Individual #1's photo in the record was not current. The photo in the record was dated 8/12/23. The photo is to be updated annually. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Individual #1's photo and personal information sheet was updated on 9/24/24. |
09/24/2024
| Implemented |
| Article X.1007 | Staff #3's Criminal background Check was completed on 7/2/24. Staff #3's date of hire was 6/26/24. Their 1st day working with Individuals was on 7/2/24. Staff #3 criminal background check came back as having a criminal record. The criminal record report was not obtained until 7/9/24. | When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application. | Applicants will not being working with individuals until their criminal background check is received and reviewed. Applicants with criminal backgrounds will review their record with management prior to having contact with individuals. Management will determine if the staff is eligible for hire based on the nature of the record, how long it has been since the criminal offenses occurred, and if their is evidence that the staff has been rehabilitated. |
10/04/2024
| Implemented |