| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(b) | There was a softball amount of lint left in the lint trap at the time of the inspection. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Immediate Action! The program manager directed staff to remove the lint on the day of inspection
The agency shall ensure that all sFloors, walls, ceilings and other surfaces shall be free of hazards.
This remediation has been completed. |
10/14/2024
| Implemented |
| 6400.68(b) | At the time of the inspection the water in the individual's bathroom read 139.2. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The program manager and site manager are assigned to fix this.
The agency shall ensure that hot water temperature does not exceed 120 degrees Fahrenheit
The correction was done immediately.
On 10/11/24, the program director educated the DSPs on the allowable water temperature for the home and said that it should never exceed 120 degrees to prevent accidental scalding. See video attachement |
10/11/2024
| Implemented |
| 6400.82(f) | There were no paper or cloth towels for use after handwashing in the bathroom | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | The program manager is responsible for making this correction.
A paper towel dispenser plus paper towel must be installed in every bathroom
The dispenser has been installed. Installation date was 10/11/2024
On the 11th of October the Agency installed paper towel dispensers in every unit. The installed dispensers are high capacity and would hold large amounts of paper towels that would last for an extended period. |
10/11/2024
| Implemented |
| 6400.110(a) | There was no smoke detector located in the attic at the time of the inspection. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | The program manager is responsible for this fix.
The agency shall ensure that every habitable floor has an automatic smoke detector.
The issue was fixed on the day of the inspection. A new smoke detector was installed in the attic. See attachement. |
09/25/2024
| Implemented |
| 6400.166(a)(11) | Individual #1's MAR did not include the diagnosis and or purpose for the medications. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | The Agency nurse/Medical director/Program specialist is responsible for this
The agency shall ensure all Medication records reflect the diagnosis or purpose of the medication.
The agency has completed updates to medication in MARs that do not reflect the purpose of the medication. |
10/15/2024
| Implemented |