| 6400.64(a) | Upon entering Individual #2's bedroom, the room was observed to be cluttered and disorganized. Clothing, shoes, boxes, personal items, and various pieces of trash were scattered and piled on the floor and on multiple surfaces, and the bed was unmade with no sheets, creating obstructed walking areas and poor overall housekeeping.
In Individual #3's bedroom, there was an open jar of pickles on the windowsill, along with empty cans of Dr. Pepper and other debris. | Clean and sanitary conditions shall be maintained in the home. | The Program Manager met with Individual 2 to discuss the identified sanitation concerns and offer assistance with cleaning the bedroom in a manner that respects the individual's privacy, preferences, and rights. Staff offered the individual choices about when cleaning occurs, which staff provide assistance, and the preferred level of participation.
If the individual continues to decline assistance, staff will document refusals and refer the concern to the Program Specialist and ISP team to develop individualized strategies to address sanitation and potential health and safety risks. |
10/09/2026
| Implemented |
| 6400.72(b) | The screen in Individual #2's bedroom was altered to accommodate the air conditioner, resulting in a visibly damaged screen. | Screens, windows and doors shall be in good repair. | A maintenance ticket was submitted to repair the screen |
10/12/2026
| Implemented |
| 6400.112(d) | The 02/16/26 Fire Drill took 49 minutes and 15 seconds, which exceeds the maximum regulatory timeframe. No other drill was on record for the month of February. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | The manager reviewed and corrected the fire drill. The drill took 49.15 seconds and was documented incorrectly. The manager noted on the form that the drill was under the required time. The managers received retraining on accurate documentation. |
10/12/2026
| Implemented |