| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | On 8/15/2024 at 10:15am, a 32 fluid ounce spray bottle of Clorox Cleaner + Bleach with instructions to contact poison control if ingested and a 16 fluid ounce bottle of Scrub Free Toilet Bowl Cleaner with instructions to contact a poison control center or physician if swallowed were observed unlocked under the sink in the second-floor full bathroom. On 8/15/2024 at 11:43am, a 1-quart can of Behr Interior Ceiling Paint and a 1-gallon bucket of DAP Dry Dex heavyweight spackling, both with instructions to contact poison control if ingested, were observed under the steps in the unlocked basement. Individual #1's assessment, completed 12/1/2023 states that she requires verbal prompting to use and avoid poisons. [Repeat violation: 3/5/2024 et al and 7/17/2024] | Poisonous materials shall be kept locked or made inaccessible to individuals. | The revision was emailed to the team. The individual is independent with poisons and does not require verbal prompts or physical prompts to avoid poisons per assessment and ISP. |
09/04/2024
| Implemented |
| 6400.64(a) | On 8/15/2024 at 11:27am, multiple piles of wig hair of varying size and color were observed on the floor in Individual #1's bedroom. On 8/15/224 at 11:29am, the ceiling vent in the second-floor full bathroom was observed with dirt and dust built up in the vent slats. On 8/15/2024 at 11:40am, the inside of the oven was observed with food splatters built up on the inner walls, door, and racks. [Repeat violation: 3/5/2024 et al and 7/17/2024] | Clean and sanitary conditions shall be maintained in the home. | The individual purchased a bin for her wigs. The vents were cleaned. The oven was cleaned. |
09/04/2024
| Implemented |
| 6400.67(b) | On 8/15/2024 at 11:46am, a small puddle of water, measuring approximately three inches by six inches was observed in the doorway between the basement and garage. [Repeat violation: 3/5/2024 et al and 7/17/2024] | Floors, walls, ceilings and other surfaces shall be free of hazards. | The floor was immediately dried. The walls and flooring above the area was assessed for leaks. |
09/23/2024
| Implemented |
| 6400.72(b) | On 8/15/2024 at 11:29am, the window in the second-floor full bathroom was observed with a broken frame. The frame had multiple pieces of plastic broken off on the left and bottom sides of the interior frame. On 8/15/2024 at 11:30am, the window in the second-floor hall was in disrepair. The lower windowpane was crooked in the frame, the handle to lift the window open had three missing pieces of plastic that had been broken off, and there was a gap in the lower left corner where the window was not sealing properly. On 8/15/2024 at 11:46am, the storm door on the rear basement exit was observed with a gap at the bottom measuring approximately one inch. The door was not properly sealing to protect against infestation of insects and rodents. [Repeat violation: 3/5/2024 et al] | Screens, windows and doors shall be in good repair. | This was not a result of damage from an individual. The property owner was contacted to replace the windows. An estimate and installation date will be sent to the agency on September 6, 2024. The agency was informed that window installation is around 4-6 weeks out for scheduling. |
10/21/2024
| Implemented |
| 6400.73(a) | On 8/15/2024 at 11:44am, the exterior staircase leading from the driveway to the lower area in the yard did not have a secure handrail that extended to the bottom three steps. [Repeat violation: 3/5/2024 et al and 7/17/2024] | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | A handrail was placed in the backyard of the home. |
09/04/2024
| Implemented |
| 6400.80(a) | On 8/15/2024 at 11:44am, the exterior staircase leading from the driveway to the lower area of the yard was observed with the third step from the bottom missing chunks of concrete. Additionally, the two bottom steps appear to have shifted over time and are no longer in alignment with the rest of the steps, creating a potential tripping hazard. [Repeat violation: 7/17/2024] | Outside walkways shall be free from ice, snow, obstructions and other hazards. | The step was patched with cement. |
09/04/2024
| Implemented |
| 6400.80(b) | On 8/15/2024 at 11:45am, a pile of haphazardly thrown bricks, pieces of broken brick, and pieces of broken concrete were observed leaning on the mesh fence that separates the driveway from the neighbor's yard. [Repeat violation: 3/5/2024 et al and 7/17/2024] | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The debris was removed after a tree fell on the neighbor¿s house. |
09/04/2024
| Implemented |
| 6400.114(b) | On 8/15/2024 at 11:44am, two cigarette butts were observed on the rear patio. A cigarette disposal container was observed to the left of the rear basement door; however, the agency's safe smoking policy was not being followed. The policy states "We advise our employees and residents to extinguish their cigarette and discard the only in appropriate containers." | Written smoking safety procedures shall be followed. | The debris was immediately removed from the front of the home. |
09/23/2024
| Implemented |
| 6400.171 | On 8/15/2024 at 11:33am, a 13.75 ounce box of Idahoan Mashed Potatoes and a 12 fluid ounce bottle of Giant Eagle Hot Sauce were observed open to contamination in the pantry cupboard on the far right of the kitchen. On 8/15/2024 at 11:35am, a mushy green bell pepper was observed in the crisper drawer in the refrigerator. On 8/15/2024 at 11:38am, a 20 ounce container of Great Value Pure Cane Sugar, a 16 ounce box of Barilla Medium Shells, and a 32 ounce bag of Essential Everyday Pure Light Brown Sugar were observed open to contamination in the upper pantry cupboard to the left of the sink. On 8/15/2024 at 11:39am, an open 8 ounce container of giant eagle grated parmesan cheese with instructions to refrigerate after opening was observed in the upper pantry cupboard to the left of the sink. [Repeat violation: 3/5/2024 et al and 7/17/2024] | Food shall be protected from contamination while being stored, prepared, transported and served.
| The items in questions were immediately discarded. |
09/13/2024
| Implemented |
| 6400.163(h) | On 8/15/2024 at 10:41am, Meloxicam 15mg tab prescribed to individual #1 was observed in the locked second-floor staff office with an expiration date of 8/7/2024. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | The medication was replaced and destroyed in a safe manner. |
09/04/2024
| Implemented |
| 6400.166(b) | On 8/15/2024 at approximately 11:21am, it was observed that Metronidazole 500 mg tab, prescribed to Individual #1, was documented as a refusal on 8/15/2024 at 9:12am by Chief Executive Officer #1 for the 8:00pm dose on 8/15/2024. On 8/15/2024 at approximately 11:21am, it was observed that Melatonin 5 mg tab, prescribed to Individual #1, was documented as a refusal on 8/15/2024 at 10:16am by Direct Service Worker #2 for the 8:00pm dose on 8/15/2024. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The chief executive officer and direct support worker #2 received a medication observation and Therap Medication Administration Record retraining on September 3, 2024. |
09/23/2024
| Implemented |
| 6400.182(c) | Individual #1's support plan, last updated 5/7/2024, states, "[Individual #1] understands cleaning chemicals and would not be at risk to ingest" while their assessment, last updated 12/1/2023, states indicates that Individual #1 is a level 4 and would require verbal prompting to use and avoid poisonous substances. [Repeat violation: 7/17/2024] | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The revision was emailed to the team. The individual is independent with poisons and does not require verbal prompts or physical prompts to avoid poisons per assessment and ISP. |
09/04/2024
| Implemented |
| 6400.186 | Individual #1's Restrictive Procedure Plan, last updated 3/18/2024, states that sharps must be locked to protect the individual's health and safety. On 8/15/2024 at 11:37am, six push pins, five nails, and a broken combination lock with a sharp edge were observed in the kitchen drawer across from the refrigerator. On 8/15/2024 at 11:38am, a cork board with approximately ten push pins was observed in the dining room. On 8/15/2024 at 11:42am, two screws were observed on a shelf located on the wall across from the steps in the unlocked basement. | The home shall implement the individual plan, including revisions. | Immediately, household items with sharp edges were discarded. The cork board was removed and will be replaced with a magnetic dry/erase board. |
09/23/2024
| Implemented |