| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Poisonous materials are not kept locked or inaccessible to individuals. Individual #1's Individual Service Plan indicates that the individual is not safe with poisons and the Individual Service Plan does not assess the individual's safety with personal hygiene products. There was a tube of Colgate toothpaste located in the bathroom that was not locked. The tube states to "Contact Poison Control." | Poisonous materials shall be kept locked or made inaccessible to individuals. | Residential Director Frank Kibaara and Managing Director, Beth Sell coordinated with the individual's Supports Coordinator for clearer verbiage in the ISP with regard to this individual not needing these items locked. Please see the documents sent with images sending via email. |
03/13/2025
| Implemented |
| 6400.64(a) | Clean and sanitary conditions are not maintained in the home. There were mouse droppings located in an empty drawer in the kitchen and on the windowsill in the basement of the home. The number of droppings did not appear to indicate an infestation, but that there had been a mouse in the home at some point. | Clean and sanitary conditions shall be maintained in the home. | Residential Director, Frank Kibaara, coordinated services with an exterminator to assess and treat the home for mice presences, the droppings were cleaned from the affected surfaces. Please see the documents with images sending via email. |
03/26/2025
| Implemented |
| 6400.163(h) | Prescription medications that are expired are not disposed of properly. There was a tube of Neosporin located in one of the first aid kits in the home that was expired in 2023 and not disposed of properly. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Residential Director Frank Kibaara, corrected at time of inspection by removing the item and educating the staff to same. All items in the kit must be up to date and not expired. Please see the document with image sending via email. |
03/05/2025
| Implemented |
| 6400.165(a) | Prescription medications are not prescribed in writing by an authorized prescriber. There were two packets of Tylenol located in one of the first aid kits in the home. This medication was not prescribed to the individual residing in the home. | A prescription medication shall be prescribed in writing by an authorized prescriber. | Residential Director Frank Kibaara, corrected at time of inspection by removing the item and educating the staff to same. Tylenol can not be placed in the First Aid Kit from manufactures. Please see the document with image sending via email. |
03/05/2025
| Implemented |