| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.73(a) | The handrail leading from backsteps outside of the kitchen to the concrete patio wobbled back and forth when you grabbed/touched the handrail. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | QLHS designated person will repair handrail from outside backsteps from the kitchen to ensure the health and safety of the individual served by QLHS. |
07/30/2025
| Accepted |
| 6400.77(b) | At the time of the inspection, the first aid kit did not contain antiseptic. (Repeat Violation 5/20/24) | 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. | QLHS has places antiseptic into the first aid kit to ensure the health and safety of the individual we serve. |
06/30/2025
| Accepted |
| 6400.112(c) | The fire dill that was conducted on 4/2/25 at 6am did not include the exit route used as "yes" was indicated in this section of the form. The fire dill that was conducted on 1/3/25 at 6:30 pm did not include the exit route used as "2/2 staff" was indicated in this section of the form. (Repeat Violation 5/20/24) | 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. | QHS will retrain staff on how to fill out the fire drill forms, and its entirety as required by QLHS and ODP. Also to ensure that the individual is evacuating the home in a timely manner as stated in ODP regulations. |
07/30/2025
| Accepted |
| 6400.15(b) | The agency will use the department licensing inspection instrument for the community homes to measure compliance. The self-inspection tool provided at the time of inspection were completed on incorrect forms. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | QLHS Director that completed the self-assessment form has been shown where to find the correct inspection instrument self-assessment measure form. |
07/01/2025
| Implemented |