| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency completed a self-assessment of the home on 6/23/2024. The certificate of compliance expired on 6/18/2024. | 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.
| COO has scheduled the next self-assessment for the week of October 1, 2024. |
10/04/2024
| Not Implemented |
| 6400.64(a) | On 7/24/2024 at 10:20AM, the window tracks of the windows in Individual #1's bedroom, the vacant bedroom, and the kitchen contained an inordinate amount of dirt, debris, and dead bugs. Individual #1 demonstrated that the built-up debris made it difficult for the window in Individual #1's bedroom to open and close. On 7/24/2024 at 10:20AM, the window ledges throughout the home to include the window ledges in Individual #1's bedroom, the vacant bedroom, the kitchen, and the basement were had an inordinate amount of dirt, debris, and dead bugs. On 7/24/2024 at 10:32AM, the floors and baseboards in the basement bathroom had a significant amount of built-up dirt and debris. On 7/24/2024 at 10:36AM, the floor in the basement laundry room was observed with dirt, debris, and dead bugs built-up along the edges. On 7/24/2024 at 10:49AM, the carpet in the bedroom hall, near the top of the basement steps had a dark stain measuring approximately two feet in length. On 7/24/2024 at 10:50AM, the baseboards and furnace vents in the living room were coated with a thick layer of dirt and dust | Clean and sanitary conditions shall be maintained in the home. | Staff cleaned areas mentioned 7/24/24. Maintenance deep cleaned the site 8/16/24. |
08/16/2024
| Not Implemented |
| 6400.64(b) | On 7/24/2024 at 10:32AM, multiple bugs to include but not limited to spiders and daddy-longlegs were on the floor and suspended from cobwebs in the full basement bathroom. | There may not be evidence of infestation of insects or rodents in the home. | Maintenance deep cleaned the site 8/16/24 and removed spiders and any signs of bugs during cleaning. |
08/16/2024
| Not Implemented |
| 6400.65 | On 7/24/2024 at 10:33AM, the full basement bathroom mechanical vent was coated with dirt, dust and debris which obstructed the function of the vent. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Staff cleaned vent 7/24/24. Maintenance deep cleaned the site 8/16/24 including vent. |
08/16/2024
| Not Implemented |
| 6400.67(a) | On 7/24/2024 at 10:36AM, the ceiling in the basement was missing drywall and exposed fiberglass insulation. On 7/24/2024 at 10:49AM, the wall in the hallway across from the kitchen doorway had two 2-inch diameter holes in the plaster. | Floors, walls, ceilings and other surfaces shall be in good repair. | Maintenance request was submitted 7/24/24. Expected completion date 8/30/24. |
08/30/2024
| Not Implemented |
| 6400.67(b) | On 7/24/2024 at 10:35AM, there was an unidentified black and white substance that appeared to be mold on multiple walls in the basement of the home to include the walls inside of the utility closet, the walls on the exterior of the utility closet, the walls in the hallway across from the laundry room, and the walls in the room of the basement with the exterior egress. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Site was temporarily closed 7/24/24. Mold company was contacted and have mitigated all sign of mold as of 8/13/24. |
08/13/2024
| Not Implemented |
| 6400.72(a) | On 7/24/2024 10:20AM, the screen in the window above Individual #1's bed did not provide a tight seal. There was approximately a one-half inch gap on the left side of the screen. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Maintenance addressed the tight seal of the window and has ordered screens 8/5/24. |
08/05/2024
| Not Implemented |
| 6400.77(b) | On 7/24/2024 at 10:15AM, the first aid kit did not contain tweezers. | 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. | Site supervisor added tweezers to the first aid kit 7/24/24. They were missing due to them being in use. |
08/26/2024
| Not Implemented |
| 6400.105 | On 7/24/2024 at 10:37AM, an excessive build-up of lint, cobwebs, and soiled clothing was behind the washer and dryer in the basement of the home. | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| Maintenance deep cleaned the site 8/16/24. |
08/16/2024
| Implemented |
| 6400.112(e) | The most recent fire drill held during sleeping hours was on 8/2/2023. | A fire drill shall be held during sleeping hours at least every 6 months. | COO created a fire drill schedule for management team and team leads 7/24/24. August 14, 2024 fire drill was completed during sleeping hours. |
08/14/2024
| Not Implemented |
| 6400.112(f) | All monthly fire drills held between 7/11/2023 and 6/5/2024 used the front door as the exit route. | Alternate exit routes shall be used during fire drills. | COO created a fire drill schedule for management team and team leads 7/24/24. August 14, 2024 fire drill was completed during sleeping hours and staff were instructed by site supervisors to use a different exit. |
08/14/2024
| Not Implemented |
| 6400.144 | Individual #2 was evaluated at the hospital on 11/30/2023 where an emergency ultrasound was ordered to be completed within 24 hours. As of 12/6/2023, the ultrasound had not been completed. | 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.
| The individual has moved to another provider December 2023. |
08/05/2024
| Not Implemented |
| 6400.151(a) | Direct Service Worker #1 had a physical examination on 9/29/2021 and then again on 12/13/2023. Direct Service Worker #1 continued to work directly with individuals until 11/17/2023. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | 11/17/23 Staff removed by HR and scheduling until physical completed. |
03/04/2024
| Not Implemented |
| 6400.171 | On 7/24/2024 at 10:09AM, the following foods were in the refrigerator: a 12 pack of Great Value eggs with a best by date of 6/23/2024 and a 45-ounce container of Country Crock Original with a best by date of 7/16/2024. On 7/24/2024 at 10:10AM, a small saucepan filled approximately halfway with cooking oil was observed on the stove top. Staff interviews reveal, the oil was used to cook Individual #1's dinner the previous night. The oil had not been strained or transferred to an air-tight container per the FDA's safe storage recommendations. On 7/24/2024 at 10:17AM, the following foods with instructions to refrigerate after opening were in the upper pantry cupboard to the right of the kitchen sink: an 18-ounce bottle of La Choy Sweet and Sour Sauce, a 19-ounce bottle of Pampa Grapefruit Spread, a 20-ounce bottle of Welch's Concord Grape Jelly, and an 18-ounce bottle of Kraft Sweet and Spicy Barbecue Sauce. | Food shall be protected from contamination while being stored, prepared, transported and served.
| Site supervisor removed expired items on 7/24/24. Staff replaced food items the following day 7/25/24. |
08/05/2024
| Not Implemented |
| 6400.18(a)(4) | The agency became aware of an allegation of abuse on 12/15/23. Enterprise Incident Management Incident #9331084 for the allegation was not reported in Enterprise Incident Management, the Department's information management system until 12/18/23. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Abuse, including abuse to a individual by another client.
| COO conducted all staff meeting and reviewed the importance of timely reporting and reminded staff that they are mandatory reporters. COO created second Team August 16, 2024 to assist with EIM completion and maintenance. |
08/05/2024
| Not Implemented |
| 6400.18(a)(5) | The agency became aware of an allegation of neglect on 11/30/2023. Enterprise Incident Management Incident #9325102 for the allegation was not reported in Enterprise Incident Management, the Department's information management system until 12/6/23. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Neglect.
| COO conducted all staff meeting and reviewed the importance of timely reporting and reminded staff that they are mandatory reporters. COO created second Team August 16, 2024 to assist with EIM completion and maintenance. |
08/05/2024
| Not Implemented |
| 6400.46(b) | Direct Service Worker #1 was trained in general fire safety training on 1/15/2023 and then again on 1/22/2024. The general fire safety training completed on 1/22/2024 did not include information specific to home such as the designated meeting place. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | The training specialists updated the fire safety training lesson to include information specific to the home such as the designated meeting place 8/16/2024 to ensure fire safety trainings are compliant with 6400.46(b). |
08/16/2024
| Not Implemented |
| 6400.163(a) | On 7/24/2024, at 10:22AM, a 6-ounce bottle of Chloraseptic Sore Throat Spray was on the top shelf of Individual #1's bedroom closet. The medication did not contain a label issued by a pharmacy. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | Site Supervisor removed the chloraseptic sore throat spray on 7/24/24. |
08/26/2024
| Implemented |
| 6400.163(d) | On 7/24/2024 at 10:22AM, a 6-ounce bottle of Chloraseptic Sore Throat Spray was unlocked and accessible on the top shelf of Individual #1's bedroom closet. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | Site Supervisor removed the chloraseptic sore throat spray on 7/24/24. The individual's prescribed medication is in fact locked in his med box. |
08/26/2024
| Implemented |
| 6400.165(a) | On 7/24/2024 at 10:22am a 6-ounce bottle of Chloraseptic Sore Throat Spray was observed in the top shelf of Individual #1's bedroom closet. This medication was not prescribed to Individual #1 by a physician. | A prescription medication shall be prescribed in writing by an authorized prescriber. | Site Supervisor removed the chloraseptic sore throat spray on 7/24/24. |
08/26/2024
| Implemented |