| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.81(a) | The bedroom for Individual #1 was located in the basement of the home. The door to the outside of the home from the basement area exited to a set of eight stairs that lead up to grade level. | An individual's bedroom may not be located in basements. Any level from which there is a standard door leading from that level directly outside to grade level is not considered a basement. | The regulation is to protect the individual in freely entering and exiting. The location of bedrooms is important for safety reasons. At the time of the inspection, the individual bedroom was in the basement, however the basement has a door leading outside with stairs. Individual relocated upstairs. |
03/14/2024
| Implemented |
| 6400.81(h) | The bedroom for Individual #1 did not have an exterior window that afforded a view of the outside. The window in the bedroom belonging to Individual #1 was approximately 8 inches tall and located at the top of the wall where it meets the ceiling. The view from the window was limited to the sidewalk and bottom outside wall of the house next door. | Each bedroom shall have at least one exterior window that permits a view of the outside. | This regulation permits for individual to have a view of the outside of the house.
The window was not wide enough to show all outside view. The Individual has a new bedroom upstairs. |
03/14/2024
| Implemented |
| 6400.81(k)(5) | There was no closet in the bedroom inhabited by Individual #1. | In bedrooms, each individual shall have the following: Closet or wardrobe space with clothing racks and shelves accessible to the individual. | Closet is important for the individual to have a place for their close and feet wear kept
At the time of inspection, the individual did not have his closet within his room. We relocated the individual to the first-floor room. Picture of his closet in his room has been sent. |
03/15/2024
| Implemented |
| 6400.101 | The hallway area noted to be the location of the individual's closet was behind a door that had a keyed deadbolt on the closet side. If an individual was in the closet area it would be possible to lock them in the area so that they would be on the keyed side of the door with no ability to open the door without a key. Egress to a fire exit was obstructed by the keyed deadbolt.
The door leading down to the basement bedroom of Individual #1 had the keyed side on the bedroom side of the door. Obstructing egress to the upstairs in the event of a fire. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| This regulation is to prevent fall caused by obstruction and create a free and non-hazardous escape route especially in the case of emergency.
The door leading to the basement had the key lock on the basement side. Our maintenance has fixed the lock, and the staff have a key to the door. |
03/15/2024
| Implemented |
| 6400.112(c) | Documentation of the drill conducted on 12/1/23 did not indicate the exit used.
The documentation of the drill conducted on 2/27/24 did not indicate the correct time of day. AM or PM was not indicated. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | This regulation is important in keeping date, and time of the drill. Fire emergencies can occur at any time and all documentation should be accurate to ensure our individuals are always safe.
At the time of the inspection, the fire drill conducted on 12/1/23 did not indicate the exit route and 2/27/24 did not indicate time of the day. The incident manager of the agency oversees the drills now and has made some changes that will ensure accountability. |
03/15/2024
| Implemented |
| 6400.144 | On 2/15/24 Individual #1 was recommended to have s "step stool" in their bathroom to aid in toileting. At the time of inspection there was no step stool in bathroom as recommended. | 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.
| Individual health is essential, and all medical recommendations are to be provided.
At the time of the inspection, a step stool was recommended to aid in toileting but was not provided. The step stool was purchased and is placed in the individual bathroom. |
03/15/2024
| Implemented |
| 6400.163(h) | The Flonase for Individual #1 was discontinued on 2/9/24. The Flonase remined in the locked medication box and on the Medication Administration Record (MAR) at the time of inspection. It was not marked as discontinued on the MAR or removed from the home and discarded as required. Corrected at time of inspection. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Expired or discontinued medications could cause a serious injury or death, it is important all meds are properly checking the safe administration.
At the time of the inspection, a discontinued med was located among the individual medications. It was removed and returned to the pharmacy. |
03/14/2024
| Implemented |