| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | At 10:49AM, empty boxes, paper bags, paper advertisements and catalogs were mixed with household items in a bag in a storage room in the basement. | Clean and sanitary conditions shall be maintained in the home. | We received this violation due to storing items in the storage room of the home. We removed the paper bags and advertisements from the storage room.
This issue was resolved on 8/15/2024
Monitoring and fixing the problem responsibility lies on the house managers. Managers, supervisors, and program specialists to make sure daily checks are performed everyday as well as document any issues |
08/19/2024
| Not Implemented |
| 6400.72(b) | At 11AM, there was a half inch gap along the walls and floor around the garage door in the attached garage of the home leaving room for insects and rodents to enter the home. [Repeat Violation, 12/22/2022, 6/29/2023, 7/25/2023] | Screens, windows and doors shall be in good repair. | This occurred due to the garage door not having a rubber sealant attached to the bottom of the door. We hired a contractor to seal the bottom of the garage door.
When was the issue resolved: 8/20/24
Responsibility lies Manager of Operations to resolve this physical site issue at this level. House managers, supervisors, and program specialists to make sure they are checking garage doors to ensure that they are properly closing. If a problem is noted during the site checks, it will be reported to the manager of operations and be tracked by management team until ticket is resolved. |
08/20/2024
| Implemented |
| 6400.73(a) | At 10:37AM, the handrail on both sides of the exterior stairs leading from the deck at the back of the home were not sturdy and wobbled back and forth when in use. [Repeat Violation, 4/20/2023] | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | This occurred due to wear and tear on the back deck. We hired a contractor to inspect the deck and complete necessary repairs.
When was the issue resolved: 8/20/24
Responsibility lies on Manager of operations. House managers, supervisors, and program specialists to make sure they are decks and handrails to ensure they are in good form. |
08/20/2024
| Not Implemented |
| 6400.76(a) | At 10:10AM, four of the eight drawers in the dresser in Individual #1's bedroom were broken and off the track, falling out when opened causing a risk of injury. At 10:41AM, a chair, on the deck off the kitchen of the home, had the fabric tear along the entire length of the seat on the left side. | Furniture and equipment shall be nonhazardous, clean and sturdy. | This occurred due to wear and tear on the dresser. We removed the broken dresser and replaced with new one.
When was the issue resolved: 8/20/24
responsibility lies on Manager of Operations. House managers will handle monitoring and reporting. Supervisors, and program specialists will make sure dressers, drawers and wardrobes are in good working condition by thoroughly checking drawers. |
08/20/2024
| Implemented |
| 6400.80(a) | At 10:41AM, a broken piece of glass, approximately two by two inches, several smaller pieces of glass, a broken brick and a cement cinder block were on the ground under the deck in the back of the home posing a tripping and injury hazard. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | We removed the broken glass and cinder block from underneath the deck.
When was the issue resolved: 8/20/24
Responsibility lies on house managers. Managers, supervisors, and program specialists will also make sure yards are free of debris during their site checks during their checks. |
08/20/2024
| Implemented |
| 6400.80(b) | At 10:43, the cement patio, outside the exit door in the back of the home, had numerous cracks and was uneven making the storm door difficult to open, posing a tripping hazard. [Repeat Violation, 12/22/2022] | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The cement was cracked due to the age of the sidewalk. We had the cement replaced.
When was the issue resolved: 8/20/24.
Responsibility lies on house managers. They will report to managers, supervisors, and program specialists. If issues are observed, they will report to Manager of Operation to make sure walkways are fixed in a timely manner. |
08/20/2024
| Implemented |
| 6400.166(a)(5) | Individual #1's August 2024 Medication Administration Record did not include the strength of Albuterol AER Inhaler. [Repeat Violation, 4/20/2023] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | This occurred due to managers only checking to make sure the medication label and MAR match. We added the dose of the inhaler to the MAR.
When was the issue resolved: 8/15/24.
Responsibility lies on med passing staff. House managers, managers, supervisors, and program specialists to make sure the dosage/strength are present on the MAR. |
09/01/2024
| Implemented |
| 6400.188(c) | Individual and staff interviews revealed that Individual #1 is being given the money sent to the agency office by the Representative Payee and financial assistance is not being provided. Individual #1's assessment, completed 3/29/2024, states that Individual #1 is not able to count amounts of money independently, make purchases using the correct amount of change and check change for accuracy. | The home shall provide services to the individual as specified in the individual plan. | EV preferred to handle her own funds, we have since had a conversation with EV and how it is in her best interest for staff to assist with money on hand management. She is willing to try.
When was the issue resolved: 9/1/24.
Monitoring responsibility lies on the program specialists to make sure homes remain in compliance with self assessments and money on hand forms. |
09/01/2024
| Implemented |
| 6400.195(b) | Individual #1 has a restrictive procedure plan. Human Rights Team meetings have not been held within the last year. | The behavior support component of the individual plan shall be reviewed and revised as necessary by the human rights team, according to the time frame established by the team, not to exceed 6 months between reviews. | his violation was received because we did not have a team member with the proper credentials.
When was the issue resolved: 9/2/2024
Fixing and Monitoring the compliance will be done by the CEO. |
09/03/2024
| Implemented |