| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | At 11:41AM, there was a thick layer of what appeared to be oil and burnt food on the inside of the oven in the kitchen of the home. | Clean and sanitary conditions shall be maintained in the home. | We received this violation due to staff cooking on 8/14/2024 and daily cleanup duties were not done by overnight staff as well as the house manager not verifying the tasks were completed the following day. This issue was resolved immediately by performing a deep clean on the oven more specifically spraying oven cleaner in the bottom area, letting it set for 20 minutes, then cleaning the residue on 8/15/2024. We retrained staff in the home related to kitchen cleaning on 8/16/2024. We followed up with retraining for House managers and supervisors.
Responsibility lies on the House Manager. Managers, supervisors, and program specialists will make sure daily checks are performed everyday using specific tools. |
08/19/2024
| Not Implemented |
| 6400.67(b) | At 11:36AM, several picture frames and decorations were leaning against the wall in the dining room posing a slipping hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | This violation was received because picture frames and decorations were not hanging on the wall. We resolved by going to Target to purchase picture hanging hooks for all decorations and picture frames.
Provider¿s Plan to Maintain Compliance responsibility lies on the House Managers. Managers, supervisors, and program specialists will follow up to ensure compliance daily. |
08/27/2024
| Implemented |
| 6400.76(a) | At 11:35AM, a plastic chair with a ten-inch crack along the middle of the seat was on the patio outside the dining room of the home. | Furniture and equipment shall be nonhazardous, clean and sturdy. | We received this violation due to not properly checking for tears/cracks on external furniture. We got rid of the external furniture on 8/16/2024.
Responsibility lies on the house managers for this violation. Managers, supervisors, and program specialists will also make sure daily checks are performed everyday and done accurately. |
08/27/2024
| Implemented |
| 6400.142(a) | Individual #2's most recent dental examination was completed on 7/7/2023. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | We received this violation due to a consumer refusing to go to several dental appointments. We continued to ask and gave examples on why visiting the dentist is an important part of life. We also had individual sign a refusal form.
Provider¿s Plan to Maintain Compliance lies on the house managers. Supervisors and program specialists will verify this is being done. |
08/28/2024
| Implemented |
| 6400.142(g) | Individual #2's most recent dental hygiene plan was completed on 7/7/2023. | A dental hygiene plan shall be rewritten at least annually. | We received this violation due to a consumer refusing to go to several dental appointments. We continued to ask and gave examples on why visiting the dentist is an important part of life. We also had the individual sign a refusal form.
Provider¿s Plan to Maintain Compliance lies on the house managers. Supervisors and program specialists will verify the use of dental plans and refusal forms. |
08/28/2024
| Implemented |
| 6400.171 | At 11:37AM, a box of Uncrustables with instructions to "Keep Frozen," were being stored in the refrigerator of the home. At 11:38AM, a partially used, unsealed container of shredded cheese was in the refrigerator in the kitchen of the home. At 11:44AM, a partially used glass bottles of Garlic Vinaigrette and Thai-ger Sweet Chili Chef Sauce with instructions to, "refrigerate after opening," were in a cabinet in the kitchen of the home. [Repeat Violation, 12/22/2022] | Food shall be protected from contamination while being stored, prepared, transported and served.
| We received this violation due to staff/management not paying attention to the details on labels of food and or condiments. This issue was resolved by reorganizing the food/condiments to their appropriate place in the kitchen.
This issue was resolved on 8/15/2024
Responsibility lies on the staff. House managers, managers, supervisors, and program specialists to make sure daily checks are performed everyday while training staff how to properly label food and condiments. |
08/19/2024
| Not Implemented |
| 6400.193(b)(1) | The sharps and knives are kept locked in the home reportedly due to Individual #1's behavioral issues. Individual #1 does not have a Restrictive Procedure Plan. | For each incident requiring restrictive procedures: Every attempt shall be made to anticipate and de-escalate the behavior using methods of intervention less intrusive than restrictive procedures. | VT does not have a restrictive plan but the sharps remain locked. We reached out to VT¿s behavior specialist so that he could start working on the restrictive plan.
Behavior specialist still working on restrictive plan.
Responsibility lies on the program specialists to monitor and make sure homes remain in compliance with self-assessments and restrictive procedures. |
09/20/2024
| Implemented |