| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | The individuals residing in the home are not safe with poisons and the Soft Soap brand antibacterial liquid hand soap found on the bathroom sink is labeled with the statement to contact poison control if ingested. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Soap was locked at time of inspection. Memo was sent to all employees clarifying that not all Softsoap brands are poison safe. Training was provided on how to identify soaps that are poison safe and how to identify individuals that are poison safe. Shift Supervisors conducted inspection of all sites to ensure that proper soaps were being used. |
12/31/2023
| Implemented |
| 6400.64(a) | Clean and sanitary conditions shall be maintained in the home. The upper cabinet doors in the kitchen were sticky and tacky to the touch from cooking residue. | Clean and sanitary conditions shall be maintained in the home. | Program Manager reviewed concerns with staff regarding cleanliness of cabinets. Item was added to site chore list. Issue has been forwarded to maintenance for further follow-up. IHRS will conduct evaluation of issue in all 24 homes to ensure that this is addressed across the board. |
12/31/2023
| Implemented |
| 6400.64(f) | Trash shall be kept in closed receptacles that prevent the penetration of insects and rodents. There were several black plastic garbage bags of trash on the porch outside the home. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | IHRS purchased new garbage cans with lids and trash has been placed inside closed receptacles. Individual follow-up to the Program Manager and staff at the location occurred, Item is listed on monthly physical site checklist and should have been addressed. Staff and Program Manager were retrained on regulation 6400.64 (f). |
12/31/2023
| Implemented |
| 6400.76(a) | Furniture shall be nonhazardous, clean and sturdy. There was a small wooden storage cart with two doors on the front located in the dining room. One door was missing a knob or handle, and the knob/handle on the second door came off in the inspector's hand when it was opened. | Furniture and equipment shall be nonhazardous, clean and sturdy. | IHRS removed item from the location. Individual follow-up to the Program Manager and staff at the location occurred, Item is listed on monthly physical site checklist and should have been addressed. Staff and Program Manager were retrained on regulation 6400.64 (f). |
12/31/2023
| Implemented |
| 6400.104 | The most recent notification letter to the fire department is dated May 20, 2022 and does not contain current information; the letter states that there are two individuals residing in the home but the current census is three. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Program Managers will be retrained on the above regulation. All fire department letters will be reviewed and updated by the Program Manager for all locations. Letters will be submitted to Quality Assurance and Regulatory Compliance Manager for review. |
12/31/2023
| Implemented |
| 6400.112(c) | Written fire drill records shall record the date, time of day, evacuation time and exit route used. The fire drill record for the drill held on 12/19/2022 did not document the exit route used. The fire drill record for the drill held on 11/20/2022 did not document the time of day that the drill occurred. The fire drill record for the drill held on 9/15/2022 did not document the exit route used. | 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. | Program Manager's will be retrained on fire safety and fire drill requirements under Chapter 6400.112 (c). Program Managers will review all fire drill records and provide individual feedback to employees of missing or incorrect data. IHRS's Quality Assurance and Regulatory Compliance Manager will be responsible to collect and review all sites fire drill records on a monthly basis. |
12/31/2023
| Implemented |
| 6400.112(h) | Individuals shall evacuate to a designated meeting place. The fire drill records for the drills held on 12/19/2022 and 9/15/2022 did not document if the individuals evacuated to a designated meeting place. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | Program Manager of the home will review fire safety concerns with all individuals and provider will schedule a time for the fire chief to give additional training to consumers. All employees and consumers will be trained on meeting places for their respective sites. |
12/31/2023
| Implemented |
| 6400.32(r) | An individual has the right to lock their bedroom door. Individual #1 and Individual #2 do not have locks on their bedroom doors and it is not documented in their respective Individual Support Plans updated on 8/17/2023 for Individual #1 and 9/13/2023 for Individual #2 that they have refused a bedroom door lock. | An individual has the right to lock the individual's bedroom door. | Client #1 and client #2 will be offered locks for their bedroom doors. Any refusals will be forwarded to the treatment team and appropriate documentation will be placed into the ISP. |
12/31/2023
| Implemented |