| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | There is inadequate lighting in the basement. (Some of the bulbs were inoperable so the basement was dark) | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The lighting was replaced in the basement and additional lighting ordered ( 5/10/2022) to be added to the current basement lighting. additional lighting will be installed by 5/18/22. lead staff was retrained on the regulations that pertains to Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. |
05/18/2022
| Implemented |
| 6400.67(a) | The ceiling in the kitchen above the sink has water damage and should be repaired. | Floors, walls, ceilings and other surfaces shall be in good repair. | A handyman was contacted and per his availability he will fix/repair the ceiling on 5/18/22.. lead Staff was retrained on what to look for in regard to ceilings, floors and walls being in good repair and what the follow up steps would be if not in good repair. |
05/18/2022
| Implemented |
| 6400.72(a) | There is no screen in the bedroom window of Individual #1. (Window was open at the time of inspection) | Windows, including windows in doors, shall be securely screened when windows or doors are open. | screen had become dislodged and was put back in. maintenance will check out screen on 5/18/22 to ensure it was in securely .. lead Staff was retrained on what to look for in regard to ceilings, floors and walls being in good repair and what the follow up steps would be if not in good repair as well as checking if the Windows, including windows in doors, are securely screened. |
05/18/2022
| Implemented |
| 6400.76(a) | The closet in the bedroom of Individual #2 was off the track and should be repaired. | Furniture and equipment shall be nonhazardous, clean and sturdy. | after staff attempting to put the closet door back on track, a handyman was contacted, and they will assess the door and update the bedroom closet on 5/18/22. lead staff was retrained on the regulations that pertains to Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents as well as checking furniture for good repair |
05/18/2022
| Implemented |
| 6400.141(c)(6) | There was no current TB test on file for Individual #2 | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | individual # 1 had his tb shot given on 5/10/22 and will return on 5/12/22 to complete the follow up .
Lead staff was retrained on the importance of completing a TB and ensuring that during the annual physical all documentation and procedures ( TB , Labwork) are completed. |
05/13/2022
| Implemented |
| 6400.142(a) | The most recent dental exam for individual #2 is dated 4/27/21. At this exam the dentist requests a 6 month follow up and there is no documentation of this follow up having occurred. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | dental exam follow up was completed on 11/3/21, and the dental office was able to send over the documentation needed . Lead staff was retrained on documentation that should be completed while at a dental visit |
05/10/2022
| Implemented |
| 6400.181(e)(10) | There was no Lifetime medical on the annual assessment for individual #2 dated 7/2/21 | The assessment must include the following information: A lifetime medical history. | Since the inspection the program coordinator/program specialist resigned and the lifetime medical has been reassigned to be completed by another program specialist by 5/16/22. staff , justice speller , program specialist was retrained on what should be included with the assessment and lifetime medical history . |
05/16/2022
| Implemented |
| 6400.217 | There was no documentation for the consents for release of information for individual #2 | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| Individual's consents request for signature were sent out on 4/12/22 to his mother and they have not been signed as yet. another DocuSign request will be sent on 5/11/2022 to request signatures again. Staff was retrained on the importance of getting annual consents for all clients. |
05/11/2022
| Implemented |
| 6400.34(b) | No copy of signed individual rights statement present in file of individual #2 | The home shall keep a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights. | Consents , including individual rights was request for signature were sent out on 4/12/22 to his mother and they have not been signed as yet. another DocuSign request will be sent on 5/11/2022 to request signatures again. Staff was retrained on the importance of getting annual consents for all clients |
05/11/2022
| Implemented |
| 6400.46(b) | The agency's fire safety expert's credentials were not updated annually - staff were not trained by a fire safety expert. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Program Specialist is retaking the train the trainer fires safety training - scheduled to occur on 5/11/2022. Program coordinator was retrained on the training regulation pertaining to fire safety experts credentials being updated annually |
05/11/2022
| Implemented |
| 6400.163(g) | The following PRN medications were listed on the MAR for Individual #2 but were not present at the time of inspection:
Anbesol 10% gel
Aquaphor | Prescription medications shall be stored in an organized manner under proper conditions of sanitation, temperature, moisture and light and in accordance with the manufacturer's instructions. | the pharmacist sent out a new Aquaphor and confirmed the dc of the time limited medication anbesol. Lead staff was retrained on checking the mar and medication ongoing for accuracy . |
05/10/2022
| Implemented |