| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The inside of the oven had baked in grease and grime. | Clean and sanitary conditions shall be maintained in the home. | Quality Assurance Staff began conducting weekly physical site inspections of each residence effective June 1, 2025 (see attached). The QA or Residential Supervisor will document all findings, including minor and major deficiencies. Then Immediately report any urgent health or safety concerns to the Program Specialist and the President/CEO. The Program Specialist will Conduct comprehensive monthly inspections of all residential sites. Review and verify the weekly inspection records from the . Track recurring issues or trends and report findings to the President/CEO during the monthly Quality Review Meeting. Along with the Training coordinator the Quality Assurance staff will provide coaching or re-training to direct support staff where deficiencies are identified. All trainings will be documented on the training sign in sheet/certificate in accordance with 6400 regulations. Ensure corrective action is implemented for deficiencies within 48 hours. Oven was cleaned of the grease and grime (SEE ATTACHED) |
06/01/2025
| Implemented |
| 6400.82(f) | Individual #1's bathroom did not have a trash receptacle. | 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. | Quality Assurance Staff began conducting weekly physical site inspections of each residence effective June 1, 2025 (see attached). The QA or Residential Supervisor will document all findings, including minor and major deficiencies. Then Immediately report any urgent health or safety concerns to the Program Specialist and the President/CEO. The Program Specialist will Conduct comprehensive monthly inspections of all residential sites. Review and verify the weekly inspection records from the . Track recurring issues or trends and report findings to the President/CEO during the monthly Quality Review Meeting. Along with the Training coordinator the Quality Assurance staff will provide coaching or re-training to direct support staff where deficiencies are identified. All trainings will be documented on the training sign in sheet/certificate in accordance with 6400 regulations. Ensure corrective action is implemented for deficiencies within 48 hours. Trash can replaced (SEE ATTACHED) |
06/01/2025
| Implemented |
| 6400.113(a) | No fire safety training was available at time of review for individual #1. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | A new fire drill was conducted on 5/6 by Qusonia Edwards (Supervisor) and Dionne Edwards, and all signatures of staff are included. Documentation has been completed and retained (see attached). All staff at the home were immediately notified of the citation (insert when and how) and the importance of ensuring evacuation occurs within the regulatory timeframe. All staff were also made aware that incomplete fire drills are not accepted. Quality Assurance will review all fire drills monthly to ensure they are completed and documented accurately. If the issue persist staff will receive disciplinary action including up to termination. Individual #1 received Training (SEE ATTACHED) |
05/06/2025
| Implemented |
| 6400.141(a) | Individual #1's annual physical dated 4/11/25 was past the regulatory 1-year time period since the previous one was dated 3/28/24. The exam date 4/11/25 was also blank. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | King Family Enterprise was able to set up an appointment for individual # 1 however the individual refused to go (SEE ATTACHED). King Family Enterprise was able to reschedule the appointment for 6/30?25. King Family Enterprise will continue to support individual #1 with care and respect with a goal to attend all of his physical as per the ODP 6400 Regulations. |
06/30/2025
| Implemented |
| 6400.144 | Ibuprofen PRN was on the MAR but was not in with individual #1's medications. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| King Family Enterprise reviewed the current Medication Administration policy and have added a procedure that will assure close monitoring of all Medication including PRN provided for the Health and Safety of the Individual. Which will include tracking and managing of all Medication to ensure the Health and Safety of the individual according to ODP 6400 Regulations. Program specialist refilled the Ibuprophen medication. |
06/06/2025
| Implemented |
| 6400.151(a) | Staff #1 did not have a physical in the record. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | King Family will ensure that every employee that works outside of the commonwealth will be required to submit a FBI criminal background check at the time of being hired. King Family Enterprise is using their current Document checklist is being used by Erika Murchison (Staff Development), Kathering Rodgriuez (Aministrator Assistant) & Barbar King (CFO) which is used to assure the complaints with 6400.21(b). During the review we noticed the Staff had his physical in the file. |
06/02/2025
| Implemented |
| 6400.181(a) | Individual #1's last assessment was dated 1/8/2024 | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | King family enterprise will ensure that the Annual Assessment is completed. Dionne Davies completed the Assessment on 5/5/25. |
05/05/2025
| Implemented |
| 6400.163(h) | The medication, Senna Docusate tab, was in with individual #1's medications, but was not on the MAR. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | King Family Enterprise recognize that the Medication Administration Policy will give us the process that is needed to give our individuals the a high level of care. The Team reviewed the MAR and updated the MAR as needed. |
05/06/2025
| Implemented |
| 6400.166(a)(7) | The name of the prescriber of the medications for individual #1 was not on the MAR. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | King Family Enterprise recognize that the Medication Administration Policy will give us the process that is needed to give our individuals the a high level of care. The Team reviewed the MAR and updated the MAR as needed. The prescribers were added to the MAR (SEE ATTACHED) |
05/05/2025
| Implemented |
| 6400.181(f) | There is no documentation that the assessment for individual #1 was sent to the team 30 days prior to the individual plan meeting at the time of review | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | King Family Enterprise will ensure that an assessment is sent to the Team 30 days prior to the meeting. |
06/02/2025
| Implemented |