| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | There was no light in the bedroom belonging to Individual #1. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| overhead light in the ceiling was replaced on 6/15/23. In the meantime, the individual in that room was given a lamp so she had lighting. The fixture is now working |
06/15/2023
| Implemented |
| 6400.77(b) | The thermometer in the first aid kit was not operational. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | A new thermometer was purchased on 6/7/22 |
06/07/2023
| Implemented |
| 6400.82(e) | In bathroom #2 there was no nonslip mat located in the shower. | Bathtubs and showers shall have a nonslip surface or mat. | a tub mat was purchased on 6/7/23 |
06/07/2023
| Implemented |
| 6400.46(a) | Staff #1 was not trained annually in general Fire Safety. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Staff person 1 is scheduled to complete fire safety in college of direct support by 8/30/23. She will be suspended if training is not completed |
08/30/2023
| Implemented |
| 6400.46(b) | The agency has not provided verification that the staff #1 and staff #2 were trained annually by a fire expert. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Staff person 1 is scheduled to complete fire safety in college of direct support by 8/30/23. She will be suspended if training is not completed
Fire safety training is done in college of direct support which does meet the requirement for training done by a fire safety expert.
Staff 2 was trained in college of direct support in November 2021. That violation is snot correct |
08/30/2023
| Implemented |