| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Cobwebs were observed in the vacant bedroom between the windows. | Clean and sanitary conditions shall be maintained in the home. | WHO (Responsible Party):
The House Manager is responsible for correcting and overseeing this issue.
WHAT (Noncompliance Identified):
Cobwebs were observed in the vacant bedroom between the windows, resulting in the home not being maintained in a clean and sanitary condition.
WHEN & HOW (Corrective Actions):
Immediately upon identification, the vacant bedroom was cleaned and all cobwebs were removed from between the windows.
The House Manager and Program Specialist inspected the room to ensure clean and sanitary conditions were restored.
A review of all bedrooms on 12/19/2025, including vacant rooms, was conducted to determine whether any additional areas were out of compliance. |
12/18/2025
| Implemented |
| 6400.71 | Emergency numbers were not posted on or near the home telephone. This was corrected at the time of inspection. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| WHO (Responsible Party):
The House Manager is responsible for correcting and overseeing this issue.
WHAT (Noncompliance Identified):
Emergency telephone numbers were not posted on or near the home telephone with an outside line, as required by ODP regulations.
WHEN & HOW (Corrective Actions):
At the time of inspection, emergency contact numbers were immediately posted on or near the home telephone.
The posted information includes the telephone numbers for the nearest hospital, police department, fire department, ambulance service, and poison control center. The Program Specialist verified that the information was clearly visible and accessible.
A review of all telephones in the home with outside lines was conducted to ensure emergency numbers were posted as required.
No additional deficiencies were identified. |
12/18/2025
| Implemented |
| 6400.76(a) | The right-side closet door in the vacant room had a loose doorknob. This was corrected at the time of inspection. | Furniture and equipment shall be nonhazardous, clean and sturdy. | WHO (Responsible Party):
The House Manager is responsible for correcting and overseeing this issue.
WHAT (Noncompliance Identified):
The right-side closet door in the vacant room had a loose doorknob, making the fixture not sturdy as required by ODP regulations.
WHEN & HOW (Corrective Actions):
At the time of inspection, the loose doorknob was immediately repaired and secured to ensure it was nonhazardous and sturdy.
The Program Supervisor tested the door hardware to confirm proper function and safety. A review of all doors and door hardware throughout the home was conducted to determine whether any additional fixtures required repair. No additional deficiencies were identified.
Target Date for Completion: 12/19/2025 and ongoing. |
12/18/2025
| Implemented |
| 6400.166(a)(2) | The MAR for Individual #2 did not contain the name of the prescribing physician. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | WHO (Responsible Party):
The House Manager, Program Specialist Supervisor and Agency Nurse are responsible for correcting and overseeing this issue.
WHAT (Noncompliance Identified):
The Medication Administration Record (MAR) for Individual #2 did not include the name of the prescribing physician, as required by ODP regulations.
WHEN & HOW (Corrective Actions):
Immediately upon identification, the MAR for Individual #2 was reviewed and updated to include the name of the prescribing physician. This missing information was also shared with the pharmacy and implemented on the January MAR's.
The information was verified against the current physician order to ensure accuracy and completeness.
The Program Specialist conducted a review of all MARs for individuals receiving medications to determine whether any additional records were missing required information.
All deficiencies identified were corrected. |
01/01/2026
| Implemented |