| 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 6/25/2024. The certificate of compliance expired on 6/18/2024. In addition, pages 1, 2, and 17 of the self-assessment were not 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.
| COO has scheduled the next self-assessment for the week of October 1, 2024. |
10/01/2024
| Not Implemented |
| 6400.64(a) | On 7/24/24 at 10:08AM, the mirror in the first-floor bathroom had multiple dark black marks on the frame from what appeared to be where cigarettes were being extinguished. On 7/24/24 at 11:44AM, the toaster on the kitchen counter had an inordinate amount of discoloration from what appeared to be food stain remnants. | Clean and sanitary conditions shall be maintained in the home. | Staff cleaned the mirror and toaster 7/24/24. The individual's preferred staff rejoined the team and is able to get compliance from the individual as it pertains to policies and procedures. Maintenance deep cleaned the site 8/16/24. |
08/16/2024
| Not Implemented |
| 6400.64(f) | On 7/24/24 at 10:02AM, there was an uncovered outside trash receptacle with a white garbage bag protruding from the top, in front of the garage door of the home. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | Site Supervisor removed the trash receptacle that had no lid 7/24/24. |
08/26/2024
| Implemented |
| 6400.65 | On 7/24/24 at 10:18AM, the second-floor bathroom mechanical vent was coated in a thick layer of what appears to be 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. |
08/16/2024
| Not Implemented |
| 6400.67(a) | On 7/24/24 at 10:08AM, the first floor bathroom appears to have water damage that starts on the ceiling, where there is paint peeling back, a water stain down the side of wall, and then down to section of paneling on the wall. The paneling wood was separating from the wall and soft to the touch. | Floors, walls, ceilings and other surfaces shall be in good repair. | Maintenance came to site and addressed bathroom issues week of 8/19/24. |
08/23/2024
| Not Implemented |
| 6400.72(a) | On 7/24/24 at 10:18AM, the second-floor bathroom window was open and did not have a screen. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | 8/5/24 Maintenance has ordered screens for the second floor bathroom. |
08/05/2024
| Not Implemented |
| 6400.72(b) | On 7/24/24 at 10:25AM, the screen in open window in the staff office was detached seven inches from the window frame. | Screens, windows and doors shall be in good repair. | Maintenance addressed screen detached in window in the staff office 7/24/24. |
08/26/2024
| Not Implemented |
| 6400.76(a) | On 7/24/24 at 10:03AM, there was a green sofa chair and ottoman in the gaming room of the home with numerous dark stains. | Furniture and equipment shall be nonhazardous, clean and sturdy. | 8/16/24 Maintenance came to site to deep clean and addressed any unsanitary issue. |
08/16/2024
| Not Implemented |
| 6400.82(f) | On 7/24/24 at 10:08AM, the first floor bathroom did not contain individual clean paper or cloth towels. On 7/24/24 at 10:18AM, the second-floor bathroom did not contain soap and individual clean paper or cloth towels. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | 7/24/24 Site supervisor went to HR office to deliver clean cloth towels and soap. |
08/26/2024
| Not Implemented |
| 6400.110(a) | On 7/24/24 at 10:15AM, there was not a smoke detector on the first floor of the home. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | 7/24/24 Maintenance came to re-install smoke detector on first floor. |
08/19/2024
| Not Implemented |
| 6400.112(e) | The home did not conduct a fire drill while Individual #1 was sleeping from 6/27/23 to 6/12/24. | 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 |
| 6400.114(b) | On 7/24/24 at 10:39AM, Individual #1 was lighting cigarettes off the natural gas stove in the kitchen and smoking in the home. Individual #1 has an ash tray in the gaming room of the home that contained a multitude of extinguished cigarette butts. The agency's policy, Smoking Safety Procedure states that "It is the policy of On-Site Companionship Services, Inc that smoking inside a facility is strictly prohibited." | Written smoking safety procedures shall be followed. | The individual had been experiencing a serious of crisis and aggressive behaviors toward staff even with additional supports. 8/19/24 The individual's preferred staff returned to the agency and reviewed with the individual the importance of fire prevention and the smoking policy of the agency. |
08/19/2024
| Not Implemented |
| 6400.171 | On 7/24/24 at 10:13AM, a partially consumed can of potato chips was uncovered on the kitchen counter. A partially consumed paper cup of ice cream was uncovered in the freezer of the refrigerator in the kitchen of the home. | Food shall be protected from contamination while being stored, prepared, transported and served.
| The individual had been experiencing a serious of crisis and aggressive behaviors toward staff even with additional supports. 8/19/24 The individual's preferred staff returned to the agency and reviewed with the individual the importance of covering food to maintain sanitary conditions. |
08/05/2024
| Not Implemented |
| 6400.18(a)(5) | The agency became aware of an allegation of neglect on 5/19/24. Incident #9421226 for the allegation was not reported in Enterprise Incident Management, the Department's information management system until 5/23/24. | 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.
| 8/5/24 Incident Manager reviewed incident management requirements with staff in all staff meeting. |
08/05/2024
| Not Implemented |
| 6400.18(i) | Enterprise Incident Management incident #9339756 for an allegation of neglect had a finalization due date of 5/31/24. As of 7/30/24, the incident has not been finalized or extension has not been requested. Enterprise Incident Management incident #9421226 for allegation of neglect had a finalization due date of 6/18/24; however, the incident was not finalized until 6/20/24. | The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension. | 8/1/24 EIM team discovered CI assignment had wrong tag and it did not appear on dashboard. COO requested an extension so that CI can complete CIR based on completed investigation. |
08/01/2024
| Not Implemented |