| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Poisons shall be locked or made inaccessible to individuals. At the time of the inspection there was poisons found in the desk located in the main entrance of the home that was not locked. The poisons included pledge spray, Lysol disinfected wipes, and a bottle identified as drug buster, which is used to dissolve unused medications. (repeat violation from 9/13/23) | Poisonous materials shall be kept locked or made inaccessible to individuals. | Poisons were disposed of at time of inspection. Staff on shift received immediate follow-up regarding the items the issue. This consisted of re-training and disciplinary action. |
11/30/2024
| Implemented |
| 6400.82(f) | At the time of inspection, the bathroom did not contain hand soap as required. | 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. | Program Manager and DSP's working at location will be re-trained in the above mentioned regulation. Soap was placed in the bathroom. |
11/30/2024
| Implemented |
| 6400.112(a) | An unannounced fire drill shall occur monthly. At the time of the inspection there was no drill documented for December 2023. ((repeat violation 9/13/23)) | An unannounced fire drill shall be held at least once a month. | Program Manager and CEO met to discuss concerns of repeat violation. Program Manager understands that issues like this moving forward will be subject to disciplinary action. Program Manager presented CEO with checklist to ensure fire drills are not missed moving forward. All staff in the home will be retrained on the regulation. |
11/30/2024
| Implemented |
| 6400.112(c) | The fire drill dated for 9.24.24 did not list an exit route used for the drill. The fire drill record shall be kept of the date, time, evacuation time, and the exit used. (repeat violation from 9/13/23) | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Program Manager and CEO met to discuss concerns of repeat violation. Program Manager understands that issues like this moving forward will be subject to disciplinary action. Program Manager presented CEO with checklist to ensure fire drills are not missed moving forward and all relevant information is present. All staff in the home will be retrained on the regulation. |
11/30/2024
| Implemented |
| 6400.112(d) | 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 employee 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 home has an extended evacuation time of four minutes for sleeping hours only. The documentation from the fire chief for the extended evacuation time did not include whether individuals should evacuate outside of the home or to a fire-safe area. A statement attesting that the extended time (and fire-safe area is based on the design and construction of the home and not on the needs of the individuals served. An attestation that the fire safety expert meets the qualifications as specified in Chapter 6400. (repeat violation 9/13/23) | 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. | CEO met with Program Manager and Quality Assurance and Compliance Manager. Fire Chief is being contacted to discuss regulation and make necessary adjustments. |
11/30/2024
| Implemented |
| 6400.112(e) | A sleep drill must be held every 6 months. There was a sleep drill documented on 4.27.24 at 10pm. Sleep times are between 11pm and 7am. The April drill did not meet the criteria for a sleep drill. The previous sleep drill was 10.25.23 which occurred at 6am. This resulted in the agency being out of compliance for completing a sleep drill every 6 months. (repeat violation 9/13/23) | A fire drill shall be held during sleeping hours at least every 6 months. | Asleep drill will be conducted for the month of November 2024. "Regulation Blast" regarding asleep drills was issued company wide. |
11/30/2024
| Implemented |
| 6400.141(a) | The individual shall have a physical exam 12 months prior to admission and annually thereafter. Individual #1 had an annual physical on 4.3.23. The follow up annual physical was scheduled on 4.5.24 however the individual refused this apt. (repeat violation 9/13/23) | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Program Manager met with client to discuss importance of medical appointments and review desensitization plan. Team met to discuss concerns of non-compliance. |
11/30/2024
| Implemented |
| 6400.142(a) | Individual #1 had a dental exam on 4.10.23 with a follow up exam on 4.15.24. Individual #1 refused the dental exam on 4.15.24. The rescheduled dental exam did not occur until 9.13.24. This exceeds the annual time frame. (repeat violation 9/13/23) | 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. | Program Manager met with client to discuss importance of dental hygiene and review desensitization plan. |
11/30/2024
| Implemented |
| 6400.143(a) | If an individual refuses routine medical or dental appointments or medical treatment, the refusal and attempts to train the individual about the need for health care shall be documented. The individual refused his CPAP machine on a daily basis, he refused his eye appointments since November 2023, he refused his annual PCP appointment, and his annual dental apt. There was no training documented pertaining to any of these refusals. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | Staff will be trained on how to implement the desensitization plan for above mentioned client. Plan will be reviewed with individual prior to every appointment and documentation will be presented to ensure review occurred. |
11/30/2024
| Implemented |
| 6400.144 | Individual #1 had a podiatrist appointment on 6.24.24 with a follow up appointment on 8.16.24. There was no documentation that reflects the individual attended this apt. Medical services shall be provided for. (repeat violation 9/13/23) | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| CEO met with Program Manager. It was reported that individual refused appointment. CEO discussed importance of maintaining documentation to ensure that the provider is accurately representing all attempts to provide necessary care. |
11/30/2024
| Implemented |
| 6400.181(e)(5) | Individual #1 annual assessment dated November 7, 2023, did not include the individual's ability to self-administer medications. | The assessment must include the following information: The individual's ability to self-administer medications. | CEO met with Program Manager. Program Manager was retrained on the above regulation. Program Manager was provided assessment template to ensure all assessments contain required information. |
11/30/2024
| Implemented |
| 6400.181(e)(6) | Individual #1 annual assessment dated November 7, 2023, did not include the individual's ability to safely avoid poisonous materials. | The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | CEO met with Program Manager. Program Manager was retrained on the above regulation. Program Manager was provided assessment template to ensure all assessments contain required information. |
11/30/2024
| Implemented |
| 6400.181(e)(7) | Individual #1 annual assessment dated November 7, 2023, did not include the individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | CEO met with Program Manager. Program Manager was retrained on the above regulation. Program Manager was provided assessment template to ensure all assessments contain required information. |
11/30/2024
| Implemented |
| 6400.181(e)(8) | Individual #1 annual assessment dated November 7, 2023, did not include the individual's ability to evacuate in the event of a fire. | The assessment must include the following information: The individual's ability to evacuate in the event of a fire. | CEO met with Program Manager. Program Manager was retrained on the above regulation. Program Manager was provided assessment template to ensure all assessments contain required information. |
11/30/2024
| Implemented |
| 6400.46(d) | Program specialist, direct service providers, shall be trained with in 6 months of employment and annually thereafter by a certified trainer in first aid, Heimlich techniques, and CPR. Staff #1 did not have documentation to reflect that they received training in the above categories. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | IHRS was in compliance but could not provide documentation during inspection. We are reviewing are files to ensure all necessary documents that prove regulatory compliance are present for easy access. |
11/30/2024
| Implemented |
| 6400.165(g) | Individual #1 suffers from paranoid schizophrenia and is on medications to address the needs of his psychiatric illness. At the time of the inspection there was no documentation to reflect that medication reviews occurred for individual #1. (repeat violation 9/13/23) | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | IHRS was in compliance but could not provide documentation during inspection. We are reviewing are files to ensure all necessary documents that prove regulatory compliance are present for easy access. |
11/30/2024
| Implemented |
| 6400.169(d) | A record of training shall be kept with the name of the person being trained, the date, the source, name of trainer and documentation that the course was successfully completed. Staff #1 and #2 did not have the multiple-choice tests with their initial medication administration training. | A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed. | IHRS was in compliance but could not provide documentation during inspection. We are reviewing are files to ensure all necessary documents that prove regulatory compliance are present for easy access. |
11/30/2024
| Implemented |