| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Inside of the oven has significant spillage that appears to be grease. The oven warming drawer was dirty and grimy. | Clean and sanitary conditions shall be maintained in the home. | The Program Manager is responsible for correcting this Violation.
The program manager would ensure that every oven in every home is clean and free from any dirt or spillage.
The Program manager would ensure this fix would take effect immediately |
04/12/2024
| Implemented |
| 6400.66 | There was no light outside of the basement door entrance/exit. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The residential director would be responsible for correcting this violation
The residential director would provide replacement bulbs for the basement entrance
This violation will be corrected immediately |
03/31/2023
| Implemented |
| 6400.72(a) | The bathroom window does not have a screen. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | The residential Director is responsible for correcting this Violation.
The residential director would engage a licensed contractor to install a screen on the bathroom window.
The Violation would be completed as soon as measured screen is supplied |
04/26/2024
| Implemented |
| 6400.110(e) | There was no smoke detector in the basement and the smoke detectors on the first and second floors were not interconnected. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | The Program specialist is responsible for correcting this Violation.
The program specialist would purchase and install a smoke detector in the basement of this home
The Violation would be completed immediately. The smoke detector was installed on the 27th of March and prof was sent to the inspectors on the same day |
04/04/2024
| Implemented |
| 6400.111(a) | There was no fire extinguisher for the second floor of the home. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | The Program specialist is responsible for correcting this Violation.
The program specialist would purchase and install a fire extinguisher on the second floor of this home.
The Violation would be completed immediately. A fire extinguisher was installed on the 27th of March, and proof was sent to the inspectors on the same day. |
04/05/2024
| Implemented |
| 6400.141(c)(13) | For individual 2, the most recent physical doesn't answer if they have any allergies. | The physical examination shall include: Allergies or contraindicated medications. | The Program Specialist and DSPs responsible for correcting this violation.
Every annual physical must document if an individual has allergies.
This fix would be implemented immediately. |
04/12/2024
| Implemented |
| 6400.141(c)(14) | For individual 2, the most recent physical doesn't answer the "info pertinent to diagnosis in the event of an emergency" section. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The Program Specialist and DSPs responsible for correcting this violation.
Every annual physical must document "info pertinent to diagnosis in the event of an emergency" section.
This fix would be implemented immediately. |
04/12/2024
| Implemented |
| 6400.151(c)(2) | Staff 2's 3/21/24 physical does not list the date of the TB .chest x-ray was completed. A previous physical was requested but not provided. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | The CEO and HR is responsible for the correction of this Violation
The CEO would obtain from Staff 2 a completed chest x-ray for the 2024 calendar year
The correction to the violation would be immidiate |
04/12/2024
| Implemented |
| 6400.181(f) | For individual 2, the letter sending the assessment to the SC at least 30 days prior to the ISP meeting was not found in the record. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The program specialist shall be responsible for the correction of this violation.
The Program Specialist shall ensure that the SC receives an assessment for every resident 30 days before the ISP meeting.
This correction would be immediate. |
03/27/2024
| Implemented |