| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(b) | At the time of the 02/25/25 Inspection, two of the glass blocks in the garage window were cracked. | Screens, windows and doors shall be in good repair. | Cracked glass blocks were reported during a routine safety committee inspection on 10/18/2024. The contractor was notified by phone by the COO and glass blocks were purchased by contractor. As it is an extensive job and due to weather constraints, the contractor has not been able to get to replace these glass blocks. The contractor was again notified by COO on 3/4/2025 to check on the status of the replacement. Attachment#1d. Contractor is scheduled to complete the work by 3/19/2025, weather permitting. An item was added to the home and safety checklist by DCQM for all staff to complete monthly to check screens, windows and doors that they are in good repair Attachment #1b. Program management will monitor and review all home and safety check list at least monthly. All agency staff were notified via email on 03/07/25 on the amended home and safety checklist. Attachment #1a. |
03/07/2025
| Implemented |
| 6400.73(a) | At the time of the inspection, the left side handrail on the stairs from the living room to the 2nd floor was not properly secured. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | On 3/4/2025, our COO contacted our contractor about the loose handrail. The contractor tightened the handrail on 3/4/2025. Attachment #1e. |
03/07/2025
| Implemented |
| 6400.110(f) | At the time of the 02/25/25 Inspection the bed shaker in the 3rd floor bedroom did not shake the bed when the smoke detectors were activated, as the device was on the floor at the time the smoke detector was tested. Corrected on site. | If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. | Bed shaker was properly installed in the bed at the time of inspection. An item was added to the home and safety checklist for all staff to complete monthly to check bed shakers as required in the homes ensuring they are in good repair and properly installed in furniture. Attachment#1b. Program management will monitor and review all home and safety check list at least monthly. All agency staff were notified via email on 03/07/25 on the amended home and safety checklist. Attachment #1a. |
03/07/2025
| Implemented |
| 6400.214(b) | At the time of the 02/25/25 Inspections, there were no current Annual Assessment in the home for any of the Individuals. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| Current copies of completed Annual assessments added to individuals goal books, located inside the homes by program Specialist on 2/28/2025. Sign offs for staff training on the Annual Assessments are also included in the goal books. Each staff and sub aide will complete review of the assessments annually. |
03/08/2025
| Implemented |