| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.65 | On 1/11/2023 there was no mechanical ventilation or window inside the ensuite bathroom. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Mechanical ventilation fan was installed in the bathroom 1/12/23 by the operational Manager. [Documentation of installed mechanical ventilation for bathroom, via photograph, was received 3/16/23 and reviewed 3/17/23. DPOC by HDKP, HSLS, on 3/22/23]. |
01/13/2023
| Implemented |
| 6400.67(b) | On 1/11/2023 the sump pump located inside a hole in the floor of the basement of the home was uncovered and was surrounded with dark water causing a possible hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | On 1/11/2023 Operations Manager covered the Sump Pump area with a wooden covering to assure the area was free of of possible hazards as identified in 6400.67(a). [Estimate for installation of French drain, dated 1/15/23, was received on 3/16/23 and reviewed 3/17/23. DPOC by HDKP, HSLS, on 3/22/23]. |
04/30/2023
| Implemented |
| 6400.72(a) | On 1/11/2023 that there was no screen in the window located on the right side of Individual #1's bedroom. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Screen was mistakenly left off window when air conditioner unit was taken out, screen was placed back in bedrooms' window by operations manager, assuring compliance in 6400.72(a). [Documentation of placed window screen, via photograph, was received 3/16/23 and reviewed 3/17/23. Documentation of quarterly monitoring form, dated 2/10/23, was received 3/16/23 and reviewed 3/17/23. DPOC by HDKP, HSLS, on 3/22/23]. |
01/11/2023
| Implemented |
| 6400.72(b) | On 1/11/2023 the screen in the window located on the left side of Individual #1's bedroom has several holes that appear to have been covered by sewing another piece of screen over the holes. This left some parts of the holes on the screen exposed. | Screens, windows and doors shall be in good repair. | New screen was placed in left hand window in bedroom of individual #1 to assure compliance of 6400. [Documentation of repaired window screen, via photograph, was received 3/16/23 and reviewed 3/17/23. Documentation of quarterly monitoring form, dated 2/10/23, was received 3/16/23 and reviewed 3/17/23. DPOC by HDKP, HSLS, on 3/22/23]. |
02/01/2023
| Implemented |
| 6400.74 | On 1/11/2023 the interior stairs leading to the basement of the home did not have a nonskid surface. | Interior stairs and outside steps shall have a nonskid surface.
| non skid was placed on basement steps on 1/11/2023 by operations manager to assure compliance of 6400.74 interior stairs shall have a nonskid surface. [Documentation of non-skid surface for basement stairs, via photograph, was received 3/16/23 and reviewed 3/17/23. Documentation of quarterly monitoring form, dated 2/10/23, was received 3/16/23 and reviewed 3/17/23. DPOC by HDKP, HSLS, on 3/22/23]. |
02/01/2023
| Implemented |
| 6400.214(b) | On 1/11/2023 Individual #1's most recent assessment and psychological evaluation were not present at the home. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| On 1/11/2023, a RESIDENTIAL RECORDS binder was created: Binder contains
Individual Demographics (ID Sheet), individual Assessments, most recent phycological evaluation, annual physical, dental hygiene plan, recent incident reports(90days) was placed in all service locations, this will assure compliance with 6400.214(b) |
01/11/2023
| Implemented |