| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(b) | Floors, walls, ceilings and other surfaces shall be free of hazards. At the time of the inspection there was a golf ball size of lint found in the dryer. This is a fire hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | At the time of inspection, the lint was immediately removed from the dryer. |
09/01/2024
| Implemented |
| 6400.113(a) | An induvial shall be instructed on fire safety upon initial admission and annual thereafter in fire safety, evacuation procedures, responsibilities during a fire drill, the designated meeting place outside the building. The individual date of admission was reported to be 4.9.24, and his fire safety training is dated 4.22.24. This exceeds the regulatory requirement. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually 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 and smoking safety procedures if individuals smoke at the home. | The individual was trained on fire safety on 4/22/2024, which was after the individual's admission on 4/9/2024. Unfortunately, there is no way to go back in time and change the date in which the individual was trained on fire safety. The only way to appropriately correct this issue is by prevention of re-occurrence. Please see provider's plan to maintain compliance. |
09/01/2024
| Implemented |
| 6400.141(a) | Individual shall have a physical exam 12 prior to admission and annually thereafter. The date of admission is 4/9/24. The date of the annual physical is 4/15/24. This exceeds the time frame. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The individual's physical examination was completed on 4/15/2024 (physician's earliest available appointment), which is after the individual's admission on 4/9/2024. Unfortunately, there is no way to go back in time and change the date in which the individual's physical examination was completed. Please see provider's plan to maintain compliance. |
09/01/2024
| Implemented |
| 6400.141(c)(15) | The annual physical shall include instructions for the individual's diet. The area of nutrition and diet on individual's physical dated 4.15.24 was left blank. | The physical examination shall include:Special instructions for the individual's diet. | During next scheduled primary care appointment, Individual #1¿s diet will be reviewed and documented on medical appointment form. |
09/01/2024
| Implemented |
| 6400.151(a) | 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. Staff #1 had a physical exam on 8.10.21 and not again until 7.22.24. This exceeds the time frame. | 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 Director had a physical exam completed on 8/10/21 and not again until 7/22/2024. Unfortunately, there is no way to go back in time and change the date in which the physical exam was completed. The only way to appropriately correct this issue is by prevention of re-occurrence. Please see provider's plan to maintain compliance. |
09/01/2024
| Implemented |
| 6400.32(r) | Individual #1's bedroom door lock is a "privacy lock". This type of lock can be opened with a tool or device that is not specific to the door or lock, such as, a screwdriver or coin. These types of locks do not provide the level of privacy and security of person and possessions expected by this regulation. | An individual has the right to lock the individual's bedroom door. | 7/23/2024 provider agency changed the bedroom door lock to appropriate lock with key. |
09/01/2024
| Implemented |
| 6400.34(a) | Individual shall be informed of their rights upon admission and annually thereafter. The date of admission for individual #1 was 4/9/24 and the date the individual was informed of his rights was 4/22/24. This exceeds the time frame. | 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 was informed of their rights on 4/22/2024, which was after the individual's admission on 4/9/2024. Unfortunately, there is no way to go back in time and change the date in which the individual was informed of their rights. The only way to appropriately correct this issue is by prevention of re-occurrence. Please see provider's plan to maintain compliance. |
09/01/2024
| Implemented |