| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Individual, #4's, bedroom had a plastic trash bag (for kitchen trash cans) full of garbage.
The bathroom toilet seat and inside of toilet was dirty. | Clean and sanitary conditions shall be maintained in the home. | The individual was coached and assisted in cleaning his bedroom up. Deep cleaning and sanitization was also carried out in the bathroom |
05/01/2024
| Implemented |
| 6400.67(b) | A bowl and spoon were found on the steps of the back porch. The site staff removed them during the inspection | Floors, walls, ceilings and other surfaces shall be free of hazards. | The egress area was cleaned up and the individual who ate his breakfast cereal outside was coached to return the bowl and spoon to the kitchen sink for cleaning after every use. |
04/19/2024
| Implemented |
| 6400.71 | No emergency numbers by the telephone. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| A new escalation data chart was printed and installed by the phone in the home |
04/29/2024
| Implemented |
| 6400.82(f) | The individuals' bathroom did not have a trash can, soap, or paper or 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. | Trash can, paper towel spindle and paper towel was purchased and placed in the bathroom. |
04/29/2024
| Implemented |
| 6400.110(e) | There is a first and second floor and basement smoke detectors are 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. | A video showing interconnectivity was shared with licensing official right after the visit |
04/22/2024
| Implemented |
| 6400.111(a) | There was no fire extinguisher on the second floor of the house. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | The fire extinguisher for the first floor was mistakenly taken to the basement during a maintenance fix. the fire extinguisher has been brought back to the first floor to re-establish compliance requirements. |
04/22/2024
| Implemented |
| 6400.216(a) | Individual records including ISPs and medical records are stored in unlocked boxes in the basement. | An individual's records shall be kept locked when unattended.
| All records in the basement were relocated to the company locked storage |
05/06/2024
| Implemented |
| 6400.46(a) | The staff member present in the home did not complete the fire drill correctly when asked. He announced the fire drill to the individuals beforehand and he also removed the smoke detector from the wall in order to conduct it. | 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 member was retrained by the Associate director on how to conduct a proper fire drill |
05/17/2024
| Implemented |
| 6400.165(c) | Individual #5 self-medicates per their ISP. They took 8am mediations shortly after 10am when licensing representatives were present in the home. Although the individual self-medicates, staff need to ensure that the individual is taking medications at their prescribed times. | A prescription medication shall be administered as prescribed. | Individual has expressed desire to transition to independent living. The ability to self medicate and document in his MAR at the appropriate time required, was discussed as a goal for the individual which he gladly agreed to. Additionally, house staff were coached to understand that it is their responsibility to ensure that he is self administering the meds on time and documenting it when he doesn't. |
05/06/2024
| Implemented |
| 6400.166(b) | Individual #4 is prescribed Hydroxyz HCL 25mg tab to be taken three times a day. On two dates there were the 2pm dose did not have initials on his medication log denoting that this medication was taken. Those dates are 4/2/24 and 4/5/24. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Staff was coached on the error and the staff admitted to administering the meds and not signing . Staff was reminded and coached that it is not enough to write initials on the blister pack and sign electronic MAR but they must also initial on the paper MAR |
04/22/2024
| Implemented |