| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Mechanical ventilation has debris/dust accumulated on it and needs to be cleaned | Clean and sanitary conditions shall be maintained in the home. | Agency will immediately through the house manager and staff will ensure that all mechanical ventilation which have debris/dust accumulated on it to be clean by staff. |
11/30/2023
| Implemented |
| 6400.81(k)(6) | No mirror found in individual's 1 bedroom. | In bedrooms, each individual shall have the following: A mirror. | Agency will immediately place a mirror in individual 1 room. |
11/30/2023
| Implemented |
| 6400.106 | Furnace inspection requested but not provided, but a furnace inspection was during inspection of this home today. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| Agency will immediately conduct and document a furnace inspection. |
11/30/2023
| Implemented |
| 6400.111(f) | Fire extinguisher in the basement area was not inspected, another fire extinguisher replaced during inspection | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | Agency will immediately have a fire extinguisher inspection done for the basement area and have the inspection tag place on the fire extinguisher. |
11/30/2023
| Implemented |
| 6400.112(d) | Fire drill dated 5.18.22 indicated that the evacuation time was 2 minutes and 50 seconds. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | Agency will conduct of a new fire drill with time not more than 2 1/2 minutes of evacuation. |
11/30/2023
| Implemented |
| 6400.15(b) | The licensing inspection instrument should be completed as it applies to the home that is being assessed. For example, we wouldn't include prostate compliance on a home that houses women only and same for prostate exam where only women reside.
Or stating furnace inspection was compliant in July, but was not completed until today? | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | Agency will immediately amend the inspection instrument to meet compliance. |
11/30/2023
| Implemented |
| 6400.52(a)(1) | Staff 1 Annual training for the training year only had (7.5 hours)
Staff 2 2022 training record requested, but not provided. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | Agency will immediately conduct staff training for staff 1 and staff 2 and training record be place in staff files. |
11/30/2023
| Implemented |
| 6400.169(a) | Annual practicum med administration training not found in training record for staff 1 | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | Agency will immediately conduct an annual practicum med administration training for staff # 1 and place all training documentation in staff HR file. |
11/30/2023
| Implemented |
| 6400.169(d) | Initial med training-Observations not dated, form not dated by trainer-unable to determine when they were completed -med trainer cert. exp date-9/28/24) | A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed. | Agency will immediately amend med observations training is conducted and dated.. |
11/30/2023
| Implemented |