| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency's self-assessment windows of completion are the following: 5/23/24 to 8/3/24 and/or 3/28/24 to 6/28/24. The home's self-assessment was completed on 8/30/24. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| CLASS Quality and Compliance Coordinator (QCC) will complete quarterly self-assessments of houses. Residential house managers (RHM) will complete monthly house inspections. The self-assessment windows will be placed on the corporate calendar for continuity of completion and to ensure that dates are being met. |
12/31/2024
| Implemented |
| 6400.15(c) | The agency completed the home's self-assessment on 8/30/24, identifying the following violations: .20b .112, .113c. However, no written summary of corrections was provided. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| CLASS Quality and Compliance Coordinator (QCC) will complete quarterly self-assessments of houses. Any identified violations will be corrected and a new self-assessment will be completed showing compliance. |
12/31/2024
| Implemented |
| 6400.64(a) | On 9/26/24 at 10:35 AM, the wall behind the stove in the kitchen was found covered in dry food splatter. | Clean and sanitary conditions shall be maintained in the home. | Wall behind stove has an updated backsplash to ease in cleaning. |
12/31/2024
| Implemented |
| 6400.64(f) | On 9/26/24 at 10:08 AM, an outdoor trash receptacle was observed in the back yard of the home with a white trash bag protruding from the top, preventing its closure with a lid. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | Additional outdoor trash receptacles have been purchased for the home. |
12/31/2024
| Implemented |
| 6400.65 | On 9/26/24 at 10:14 AM, the bathroom located in the basement did not include a mechanical vent or an operable window that opens. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Bathroom in the basement has been sealed off and is no longer usable. |
12/31/2024
| Implemented |
| 6400.66 | On 9/26/24 at 10:17 AM, the kitchen door leading to the outside porch did not have an operable light. There was no other lighting source to sufficiently illuminate this egress area. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Light fixture outside has been added to provide additional illumination and safety. |
12/31/2024
| Implemented |
| 6400.80(b) | On 9/26/24 at 10:17 AM, a metal railing was observed outside of the egress from the kitchen with splintering, chipped paint and rust throughout its entirety. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | Metal railing outside has been repainted. |
12/31/2024
| Implemented |
| 6400.101 | On 9/26/24 at 10:09 AM, the rear egress of the home was found to be roughly eighty percent blocked by a bush growing onto the walkway from the basement. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| All weeds have been removed from the walkway from the basement |
12/31/2024
| Implemented |
| 6400.112(c) | The home does not have a written record of fire drills completed from October 2023 to August 2024. | 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. | Residential homes managers were all retrained on the regulations pertaining to fire drills. Fire drill log forms were updated and reviewed with all residential homes managers on 10/3/2024. |
12/31/2024
| Implemented |
| 6400.163(d) | On 9/26/24 at 10:23 AM, a medication bottle of Selenium Sulfide 2.25% that was prescribed to Individual #2 was found unlocked in the bathroom on the countertop of the vanity. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | Medications will be kept locked at all times when not in use. |
12/31/2024
| Implemented |
| 6400.207(5)(III) | On 9/26/24 at 10:24 AM, Individual #1's bed contained full bed rails that restricted the movement or function of the individual's body. The agency did not obtain a prescription for the bedrails. The most current assessment dated did not address if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual. Individual #1's individual plan does not include periodic relief of the device to allow freedom of movement. | A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Protection from injury during a seizure or other medical condition, if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement. | Residential homes manager is working with the primary care doctor to get a copy of orders for the bed rails. |
12/31/2024
| Implemented |