| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The provider did not complete a self-assessment of the home within 3-6 months of the expiration of the agency's license. The agency completed a self-assessment; however, it was not dated, and it is unknown when it was completed. | 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.
| CEO met with Program Manager to review regulation and discuss citation. Program Manager indicated that they understood citation and would correct moving forward. |
11/30/2024
| Implemented |
| 6400.64(a) | Clean and sanitary conditions are not maintained in the home. The hot/cold water knobs in the tub were completely covered with mildew. | Clean and sanitary conditions shall be maintained in the home. | Tub was cleaned immediately following inspection. |
11/30/2024
| Implemented |
| 6400.67(b) | Surfaces in the home are not free of hazards. The paper towel holder in the bathroom was broken off of the wall. There were two screws sticking out of the piece on the wall where it was broken. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Provider has contacted maintenance to repair the wall and hazards were removed. |
11/30/2024
| Implemented |
| 6400.77(b) | The first aid kit in the home did not contain antiseptic. The antiseptic in that was located in the first aid kit was expired. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | Antiseptic was removed and replaced with acceptable antiseptic that is not expired. IHRS will audit all antiseptics in first aid kits to ensure compliance across the agency. |
11/30/2024
| Implemented |
| 6400.112(c) | The fire drill conducted on 10/26/23 did not include the time that the fire drill took place. (Repeat Violation 9/13/23) | 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. | Program Manager and CEO met to discuss concerns of repeat violation. Program Manager understands that issues like this moving forward will be subject to disciplinary action. Program Manager presented CEO with checklist to ensure fire drills are not missed moving forward and all relevant information is present. All staff in the home will be retrained on the regulation. |
11/30/2024
| Implemented |
| 6400.112(d) | The home has an extended evacuation time of three minutes. The documentation from the fire chief for the extended evacuation time did not include whether individuals should evacuate outside of the home or to a fire-safe area. A statement attesting that the extended time (and fire-safe area is based on the design and construction of the home and not on the needs of the individuals served. An attestation that the fire safety expert meets the qualifications as specified in Chapter 6400. (Repeat Violation 9/13/23) | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | CEO met with Program Manager and Quality Assurance and Compliance Manager. Fire Chief is being contacted to discuss regulation and make necessary adjustments. |
11/30/2024
| Implemented |
| 6400.32(h) | Individual #1's right to privacy was violated. Individual #1 needed to utilize the bathroom during the site inspection. Staff escorted Individual #1 to the bathroom and waited to stand in the doorway with the door open while Individual #1 used the bathroom, exposing Individual #1 to other individuals, staff not assisting Individual #1 and guests in the home. | An individual has the right to privacy of person and possessions. | Incident was filed and investigation was assigned. Upon completion of investigation, IHRS will follow-up with employee to discuss concerns and issue appropriate training and/or discipline. |
11/30/2024
| Implemented |
| 6400.165(a) | Prescription medications are not prescribed in writing by an authorized provider. The first aid kit in the home contained three packets of Advil that were not prescribed to any individual in the home. | A prescription medication shall be prescribed in writing by an authorized prescriber. | Medication was removed from the first aid kit. IHRS will audit all first aid kits to ensure compliance across the agency. |
11/30/2024
| Implemented |