| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | On 8/7/2024 at 10:13am, two 17-count packages of finish Powerball Ultimate dishwasher tabs and one 263-gram package of Cascade Platinum Plus dishwasher tabs with instructions to contact poison control if ingested were unlocked under the kitchen sink. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The staff immediately remove the tabs and lock them up in the cleaning cabinet on 8/7/2024. |
09/17/2024
| Implemented |
| 6400.64(f) | On 8/7/2024 at 10:03am, two large outdoor trashcans were observed in the front yard of the home near the curb that were overflowing with trash bags and could not close to prevent insects or vermin from getting into the trash. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | Maintenance purchased an extra tote on 8/08/2024, so the lid will shut, and garbage was picked up on Monday 8/12/2024 |
08/12/2024
| Implemented |
| 6400.67(a) | On 8/7/2024 at 10:38am, the floor in the upper-level full bathroom was unfinished around the water lines and drainage pipes of the free-standing bathtub. Additionally, a circular portion of the flooring, measuring approximately four inches in diameter, had been cut in the floor, exposing the subfloor. | Floors, walls, ceilings and other surfaces shall be in good repair. | Maintenance installed a plastic flange around water lines to cover the hole in the floor 08/19/2024 |
08/19/2024
| Implemented |
| 6400.67(b) | On 8/7/2024 at 10:16am, a sewage drain cap in the basement was observed protruding approximately two inches out of the basement floor, causing a potential tripping hazard. On 8/7/2024 at 10:46am, two of the porcelain tiles in front of the decorative fireplace were cracked and have sharp edges. On 8/7/2024 at 10:46am, there was a gap in flooring along the edge of the wall at the bottom of the steps measuring approximately 1 inch in width by 2.5 feet in length, exposing the subfloor and insulation. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Maintenance painted the protruding drain cap yellow on 08/19/2024 |
08/19/2024
| Not Implemented |
| 6400.72(b) | On 8/7/2024 at 10:39am, the storm window on the exterior of the window located at the front of the home in Individual #1's bedroom was observed with a crack in the lower left corner of the glass, measuring approximately 4-inches in length. On 8/7/2024 at 10:43am, the screen in the window at the front of the home in the spare bedroom, located across the hall from individual #1's bedroom, was observed with a hole in the lower right corner of the screen, measuring approximately 1-inch across by 1.5-inches in length. | Screens, windows and doors shall be in good repair. | Maintenance repaired the screens on 08/19/2024 |
08/19/2024
| Implemented |
| 6400.141(a) | Individual #1's, date of admission 3/26/2024, had a physical examination was completed on 3/27/2024. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The program specialist contacted the physician, and the physical form was updated on 8/30/2024. |
08/30/2024
| Implemented |
| 6400.141(c)(3) | Individual #1's physical examination, completed 3/27/2024, did not include the date of the individual's most current tetanus and diphtheria vaccination. This section on the physical examination form was marked "unknown". | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | The program specialist contacted the physician, and the physical form was updated on 8/30/2024. |
08/30/2024
| Not Implemented |
| 6400.141(c)(6) | Individual #1's physical examination, completed 3/27/2024, did not include the date of the individual's most current tuberculin skin test. This section on the physical examination form was marked "unknown". | 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. | The program specialist contacted the physician, and the physical form was updated on 8/30/2024. |
08/30/2024
| Not Implemented |
| 6400.141(c)(11) | Individual #1's physical examination, completed 3/27/2024, did not include recommendation for bloodwork intervals. This section on the physical examination form was left blank. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | The program specialist contacted the physician, and the physical form was updated on 8/30/2024. |
08/30/2024
| Not Implemented |
| 6400.141(c)(15) | Individual #1's physical examination, completed 3/27/2024, did not include special instructions for the individual's diet. This section on the physical examination form was left blank. | The physical examination shall include:Special instructions for the individual's diet. | The program specialist contacted the physician, and the physical form was updated on 8/30/2024. |
08/30/2024
| Not Implemented |
| 6400.181(a) | Individual #1's, date of admission 3/26/2024, initial assessment was completed on 7/9/2024. Individual #1's initial assessment, completed 7/9/2024, indicated that the individual can use the telephone independently. Individual #1's restrictive procedure plan, last updated 3/18/2024, indicates that the individual cannot have access to a cell phone and that the individual will utilize the landline between the house of 8:00am and 10:00pm while supervised in a common area of the home. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | The program specialist updated the assessment on 8/19/2024 to reflect the individual's phone usage restrictions and sure that all DSP's are informed of the change. |
08/19/2024
| Implemented |
| 6400.181(e)(2) | Individual #1's initial assessment, completed 7/9/2024, did not include the individual's dislikes. This section was left blank. | The assessment must include the following information: The likes, dislikes and interest of the individual. | The program specialist updated the assessment on 8/19/2024 |
08/19/2024
| Implemented |
| 6400.181(e)(12) | Individual #1's initial assessment, completed 7/9/2024, did not include recommendations for specific areas of training, programming and services. This section was marked "N/A". | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The program specialist updated the assessment on 8/19/2024 |
08/19/2024
| Implemented |