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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | The hot water temperature in the home exceeded 120 degrees. Water in the home measured 130.8 degrees on the day that Individual #1 was burned. The water temperature in the home on 6/17/24 measured 138 degrees. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | In accordance with Chapter 6400.68(b), hot water in homes should not exceed 120 degrees. On June 5, an individual sustained a burn from water that exceeded this temperature. When tested, water in the home measured 130.8 on the day that the burn occurred. The temperature was lowered that day. On June 17 the water temperature had risen to 138 degrees. The home is an apartment which has a shared water source. In order to have the water temperature lowered, a work order is sent to the apartment maintenance. Maintenance is responsive but it still takes time for the request to move through their process. Since staff do not have direct access to lower the water temperature immediately, a water temperature chart has been implemented at this home. Staff are required to test the water and record the temperature prior to assisting individuals with baths/showers to prevent inadvertently causing a burn. |
06/14/2024
| Implemented |
| 6400.32(c) | Individual #1 was neglected. On June 5, 2024, Individual #! sustained a 2nd degree burn on his right buttock during a morning shower. Staff #1 was unaware that the water was burning Individual #1 until there was a blister present. Water at the home measured 130.8 degrees causing the burn.
Individual #1 wears adult briefs for incontinence. Per the Individual Service Plan, Individual #1 is to be changed regardless of whether or not his brief is soiled, every two to three hours during awake hours and every four hours during sleeping hours due to ongoing medical concerns. Individual #1 is not consistently checked and changed during sleeping hours. Staff #1 does not change Individual #1 every four hours during sleep hours. On the morning of June 5, 2024, Staff #1 found to be in two briefs that were very saturated briefs upon waking Individual #1 in the morning prior to placing Individual #1 in the shower where the individual received the 2nd degree burn. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | According to Chapter 6400.32 (c) and the individual¿s IP, this individual¿s briefs are to be changed every 3 to 4 times per day. On the evening of June 5, 2024, the individual was placed in two briefs by staff. When questioned, staff indicated they did this because the individual tends to have heavy urine flow at night. Further questions of staff led to the discovery that the individual is not changed every 3 to 4 hours as directed in his IP.
In accordance with Chapter 6400.68(b), hot water in homes should not exceed 120 degrees. On June 5, an individual sustained a burn from water that exceeded this temperature. When tested, water in the home measured 130.8 on the day that the burn occurred. The temperature was lowered that day. On June 17 the water temperature had risen to 138 degrees. The home is an apartment which has a shared water source. In order to have the water temperature lowered, a work order is sent to the apartment maintenance. Maintenance is responsive but it still takes time for the request to move through their process. Since staff do not have direct access to lower the water temperature immediately, a water temperature chart has been implemented at this home. Staff are required to test the water and record the temperature prior to assisting individuals with baths/showers to prevent inadvertently causing a burn. |
08/21/2024
| Implemented |
| 6400.185(5) | Individual #1's Individual Service Plan is not revised to contain current information. Individual #1's ISP states "Sharps, poisons/chemicals and hygiene products are locked in the home due to the needs of Individual #1's housemate." Individual #1s' housemate's Individual Service Plan states that Individual #2 is safe with poisons and these items do not need to be locked. | The individual plan, including revisions, must include the following: Risks to the individual's health, safety or well-being, behaviors likely to result in immediate physical harm to the individual or others and risk mitigation strategies, if applicable. | Chapter 6400.185 (5) states that the IP should include all risks to the individual with a plan to keep the individual safe. On or about June 17 in an unannounced inspection, it was discovered that an individual¿s supports had not been updated in the individual¿s ISP. This update was made on August 7, 2024. |
08/07/2024
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | A self-assessment was not completed for this home. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| Completed self assessments will be sent to Department of licensing by end of work day April 5, 2024. |
04/05/2024
| Implemented |
| 6400.62(c) | Poisonous materials shall be stored in their original, labeled containers. At the time of the inspection, located in Individual #2 bathroom under the bathroom sink were two blue ceramic decorative soap dispensers. When the licensing representative pumped each of the decorative soap dispensers a clear scented liquid was dispensed from each of the decorative soap dispensers. | Poisonous materials shall be stored in their original, labeled containers. | All poisonous materials were removed out of the area. All homes were checked to ensure staff/clients were following regulations pertaining to poisonous materials. |
04/05/2024
| Implemented |
| 6400.112(i) | At the time of the inspection, Staff #3 was unable to set off the smoke detectors in the home. When the Licensing Representative asked how the smoke detectors are set off for the monthly fire drills, Staff #3 responded that "fire, fire" is yelled out by staff members. Staff #3 had to call the maintenance of the building to come to the home to set off the smoke detectors, as well as explain how to properly set the smoke detectors off. Smoke detectors are not being set off during each fire drill. | A fire alarm or smoke detector shall be set off during each fire drill. | Staff # 3 was retrained on fire safety the following day. All staff will be retrained on fire safety and how to conduct a fire drill. |
04/05/2024
| Implemented |
| 6400.165(g) | Individual #2 had a medication review on 1/29/24 and the form used did not include the reason for prescribing medication. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Program specialist reviewed the individuals files for accuracy. |
04/01/2024
| Implemented |
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