| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Poisonous materials were unlocked underneath the kitchen sink, in kitchen island cabinet, in the upstairs bathroom, and in the basement. ISP's for Individual 1 and 2 indicate risk of ingestion. | Poisonous materials shall be kept locked or made inaccessible to individuals. | New locks were installed on the kitchen cabinet, bathroom stall and the basement. Photos of the locks were attached to the supporting documentation |
05/08/2025
| Implemented |
| 6400.64(a) | A mop bucket full of dirty liquid was in the corner of the kitchen. The kitchen cabinets and range hood had a noticeable buildup of grease that requires cleaning. The trash in the kitchen was leaking contents onto the floor. The drawer which contained a silverware organizer and ice cube trays contained noticeable amounts of crumbs and/or similar food debris. | Clean and sanitary conditions shall be maintained in the home. | The mop bucket was removed from the kitchen. A deep clean of the kitchen including the cabinets and range hood was completed. the trash bag on the door knob was removed and the trashcan for the kitchen was put in pace for proper use. |
05/13/2025
| Implemented |
| 6400.64(d) | The kitchen/dining room did not have a trash can. A trash bag was hanging from the knob of the back door, which was ripped and spilling contents onto the floor. | Trash in the bathroom, dining and kitchen areas shall be kept in cleanable receptacles that prevent the penetration of insects and rodents. | The trashcan was put back where it was supposed to be. A photo evidence is attached in the supporting documentation. The trash bag on the door knob was removed. |
05/08/2025
| Implemented |
| 6400.64(f) | The outdoor trash receptacle did not have a lid. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | The home had 3 trash cans; 2 had receptacles and one did not. The trash can without the receptacle has been disposed off. Phot evidence attached in supporting documentation |
05/08/2025
| Implemented |
| 6400.67(b) | At the top of the stairs leading to the second floor, the edge of the landing has a crack several inches long which is in danger of breaking off completely. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Maintenance was made aware of the issue and the riser on the stairs was repaired |
05/14/2025
| Implemented |
| 6400.82(f) | The upstairs and downstairs bathroom did not contain hand soap, toilet paper, or paper/cloth towels. | 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. | The toilet soap , tissue paper and paper towel have been placed back in the bathroom were they should be. The items were removed and taken to a new site due to a site closure that occurred on 4/25/25.the individuals returned to the home on the evening of 4/28/25 and the items were not restocked in the right locations. |
05/09/2025
| Implemented |
| 6400.83(a) | There was no silverware located in the home. While Individual 1 does require sharps to be locked as a restrictive procedure, staff could not locate where silverware/sharps were being stored during the inspection. | A home shall have a kitchen area with a refrigerator, sink, cooking equipment and cabinets for storage. | New silverware were purchased and delivered to the home. A photo of the new silverware is attached to the supporting documentation. |
05/13/2025
| Implemented |
| 6400.110(e) | The smoke detectors located throughout the home were not interconnected. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | The smoke detectors were re-tested and they worked as expected. The type of detectors is Aegis and requires the user to hold the button for at least 10 seconds for all three interconnected devices to sound off the alarm |
05/08/2025
| Implemented |
| 6400.144 | Individual 1's pharmaceutical needs could not be provided as their Epinephrine Injection PRN was not found on premises. | 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.
| A replacement was ordered from the pharmacy and it is now present in the home. |
05/08/2025
| Implemented |
| 6400.216(a) | Personally Identifying Information for Individuals 1 and 2 were stored unsecured in the kitchen island. | An individual's records shall be kept locked when unattended.
| The Program Books for individuals 1 and 2 have been relocated to the storage closet where they should be stored primarily and locked up at all times. |
05/20/2025
| Implemented |
| 6400.186 | The ISP for Individual 1 indicate that "Individual 1 does not have mini blinds or curtain rods/bedroom dresser due to these behaviors." Mini blinds, curtain rods, and a dresser were found in Individual 1's bedroom. | The home shall implement the individual plan, including revisions. | A discrepancy form was sent to the SC to update the ISP to reflect that individual has not engaged in property destruction of his blinds or dresser in the past year. As such, his ISP should be updated to reflect the change in behavior |
05/08/2025
| Implemented |