| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.65 | At 12:07PM, the wall vent in the dining room had a thick built-up layer of dust. [Repeated violation 7/23/24 et al] | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| We have contracted two cleaning companies to address all cleaning-related issues, beginning on Monday, October 28, 2024. One company will perform a one-time deep cleaning of each property, while the second company will maintain a monthly cleaning schedule to ensure ongoing upkeep. Should additional cleaning needs arise, we will adjust the cleaning frequency as necessary to maintain compliance. Our Director of Residential Facilities & Compliance will conduct walkthroughs of each property alongside the new maintenance staff to assess any residential housing damages. They will develop a completion schedule for each task, specific to each house, and hold daily meetings to review progress on completed and outstanding work. The cleaning team will submit a daily checklist detailing completed and pending cleaning tasks, including scheduled dates for unfinished work. Additionally, they will document all work with before-and-after photos to verify thoroughness and quality. |
12/16/2024
| Not Implemented |
| 6400.66 | At 12:08PM, there was no source of lighting in the garage of the home. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| We have hired two full-time maintenance staff who will start addressing all maintenance-related issues on Monday, October 28, 2024. Their primary responsibilities include assessing all damages, promptly fixing all reported maintenance violations, and maintaining the houses to ensure they are free from any further maintenance violations. They will also train staff on completing maintenance-related issue reports and perform daily maintenance check ups at all properties. Additionally, we have appointed a new Director of Residential Facilities & Compliance, responsible for overseeing all maintenance-related violations, supporting the correction of issues, and holding the maintenance team accountable. The Director will conduct comprehensive walkthroughs of each property with the new maintenance staff to assess all residential housing damages, develop a completion schedule for each task at each house, conduct daily meetings to review completed and outstanding work, submit a daily checklist of completed and pending tasks with planned completion dates, and document all work with before-and-after photos to ensure thoroughness and accuracy. |
12/16/2024
| Implemented |
| 6400.81(k)(5) | At 12:35pm, Individual #1's bedroom did not have closet or wardrobe space. At 12:36PM, Individual #2's bedroom did not have a closet or wardrobe space. | In bedrooms, each individual shall have the following: Closet or wardrobe space with clothing racks and shelves accessible to the individual. | To address the lack of closet or wardrobe space, hanging clothing racks and hangers have been ordered for Individual #1 and Individual #2. These items are scheduled to arrive on November 2, 2024. Upon arrival, maintenance staff will install the wardrobes in each bedroom to ensure they meet the required standards for personal storage. Residential Site Supervisors will verify that these closets are set up and accessible upon installation. |
12/16/2024
| Implemented |
| 6400.105 | At 12:07PM, the dryer lint trap was completely full, with a thick layer of built-up lint.[Repeated violation 7/23/24 et al] | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| We have contracted two cleaning companies to address all cleaning-related issues, beginning on Monday, October 28, 2024. One company will perform a one-time deep cleaning of each property, while the second company will maintain a monthly cleaning schedule to ensure ongoing upkeep. Should additional cleaning needs arise, we will adjust the cleaning frequency as necessary to maintain compliance. Our Director of Residential Facilities & Compliance will conduct walkthroughs of each property alongside the new maintenance staff to assess any residential housing damages. They will develop a completion schedule for each task, specific to each house, and hold daily meetings to review progress on completed and outstanding work. The cleaning team will submit a daily checklist detailing completed and pending cleaning tasks, including scheduled dates for unfinished work. Additionally, they will document all work with before-and-after photos to verify thoroughness and quality. |
12/16/2024
| Not Implemented |
| 6400.110(e) | At 12:45PM, the smoke detectors, on each of the three floors of the home, 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. | We have hired two full-time maintenance staff who will start addressing all maintenance-related issues on Monday, October 28, 2024. Their primary responsibilities include assessing all damages, promptly fixing all reported maintenance violations, and maintaining the houses to ensure they are free from any further maintenance violations. They will also train staff on completing maintenance-related issue reports and perform daily maintenance check ups at all properties. Additionally, we have appointed a new Director of Residential Facilities & Compliance, responsible for overseeing all maintenance-related violations, supporting the correction of issues, and holding the maintenance team accountable. The Director will conduct comprehensive walkthroughs of each property with the new maintenance staff to assess all residential housing damages, develop a completion schedule for each task at each house, conduct daily meetings to review completed and outstanding work, submit a daily checklist of completed and pending tasks with planned completion dates, and document all work with before-and-after photos to ensure thoroughness and accuracy. |
12/16/2024
| Not Implemented |
| 6400.171 | At 11:56AM, a container of used cooking oil was uncovered on the kitchen counter. According to the FDA's safe storage recommendations, used cooking oil should be strained, stored in an airtight container, and refrigerated for reuse. [Repeated violation 7/23/24 et al] | Food shall be protected from contamination while being stored, prepared, transported and served.
| To address improper food storage practices, all expired and improperly stored items in the refrigerator, freezer, and kitchen area were immediately discarded. Staff have been reminded of food storage protocols, including checking expiration dates and ensuring food is wrapped and protected from contamination. Additionally, a food safety flyer has been created and will be posted in the kitchen as a reminder of proper storage practices. Residential Site Supervisors will monitor food storage during their weekly inspections to ensure compliance. |
12/16/2024
| Not Implemented |
| 6400.163(b) | At 12:13PM, a loose tablet of Loratadine was in a disposable medicine cup on the desk in the unlocked staff office. Staff interviews revealed that the night shift staff popped the tablet out of the blister pack and did not administer this medication at 8:00AM. | A prescription medication may not be removed from its original labeled container in advance of the scheduled administration, except for the purpose of packaging the medication for the individual to take with the individual to a community activity for administration the same day the medication is removed from its original container. | All staff will be retrained on proper medication administration procedures, emphasizing the requirement to keep medications in their original containers until the scheduled administration. Staff will also be retrained on using the Therap system for accurate and timely documentation of medication administration. The Director of Residential Facilities and Compliance will assist in monitoring adherence to these procedures and addressing any immediate issues. |
12/16/2024
| Not Implemented |
| 6400.163(d) | At 12:14PM, Individual #2's medications were in a utility box with a padlock that was not engaged, in the unlocked staff office. [Repeated violation 7/23/24 et al] | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | Individual #2's medications will be securely stored in the utility box with the padlock properly engaged. Additionally, the staff office will be locked when not in use to ensure secure storage of medications. |
12/16/2024
| Not Implemented |
| 6400.166(b) | Nystatin cream prescribed to Individual #2 was not initialed as administered on 10/1/24 at 4:00PM and 8:00PM. [Repeated violation 7/23/2024 et al.] | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | All staff will be retrained on the correct procedures for medication administration, emphasizing the importance of immediate documentation in the medication administration record (MAR) at the time of administration. The training will include detailed guidance on using the Therap system to ensure accurate and timely recording. The Director of Residential Facilities and Compliance and Program Specialists will oversee the training and provide ongoing support. |
12/16/2024
| Not Implemented |
| 6400.167(a)(1) | At 12:13PM, a loose tablet of Loratadine was in a disposable medicine cup on the desk in the unlocked staff office. Staff interviews revealed that the night shift staff popped the tablet out of the blister pack and did not administer this medication at 8:00AM. | Medication errors include the following: Failure to administer a medication. | To address this violation, staff will be retrained on the critical importance of administering medications at the prescribed times and properly documenting each administration. Medications will be securely stored in a utility box with a proper locking mechanism to prevent unauthorized access. The staff office will be locked when not in use to ensure medications are safeguarded. Additionally, any missed doses will be immediately reported, and corrective actions will be taken to ensure compliance. |
12/16/2024
| Not Implemented |