| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.43(b)(1) | By Staff accounts and licensing also observed at additional homes that the staff could not access the computer to administer medication as needed, due to consistently slow internet and they were doing their own work arounds such as giving medication by memory and signing off on giving the medication at a different time than the medication was given, as the computers were not operating properly. This problem extends to all actions that staff need an internet accessible computer to do their work, including writing daily notes. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | The IT department resolve the ticket for internet service on 1/9/2023. See violation 1 attachment# 32. |
01/09/2023
| Implemented |
| 6400.62(c) | Spray bottle filled with unknown clear liquid observed in locked kitchen cabinet. | Poisonous materials shall be stored in their original, labeled containers. | The spray bottle filled with unknown clear liquid observed in locked kitchen cabinet was removed from the home on 12/13/2022. See violation 11 attachment#41b. |
12/13/2022
| Implemented |
| 6400.64(a) | There was a large accumulation of grease on the kitchen wall tile behind the stove and on the wall beside the stove. | Clean and sanitary conditions shall be maintained in the home. | The large accumulation of grease on the kitchen wall tile behind the stove and on the wall beside the stove has been cleaned and free of grease on 12/16/2022. See violation 5 attachment #36. |
12/16/2022
| Implemented |
| 6400.64(b) | Roach infestation in this unit. Licensing observed five roaches in the kitchen area cabinets and sink. Occupants of this unit reported roach infestation, mice activity and rat activity in this building which has been present for many years. | There may not be evidence of infestation of insects or rodents in the home. | The home was inspected by a professional technician and preformed roach, rodent mice and ant service in duplex and basement. Technician sealed cracks and crevices and treated all kitchen cabinets. Placed monitors and bait stations throughout duplex on 12/26/2022; 1/09/2023, 2/09/2023 and 2/16/23. The home is declared free from any form of infestation activity by the treating technician. See violation 6 attachment#37. |
02/16/2023
| Implemented |
| 6400.67(a) | The bathroom had a hole in the wall behind the door. | Floors, walls, ceilings and other surfaces shall be in good repair. | The hole on the wall behind the bathroom door was repaired on 12/17/2022. See violation 7 attachment#38. |
12/17/2022
| Implemented |
| 6400.67(b) | Individual #4's bedroom had exposed wires tapped to the wall. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Individual #4¿s bedroom wires and duct-tape were removed on 12/16/2022 and are not accessible to individuals and or staff. See violation 8 attachment#39. |
12/16/2022
| Implemented |
| 6400.216(a) | The kitchen contained two unlocked and unable to be locked file cabinets which contained current and previous individuals' personal information including their financial records, bank statements, individual support plan, etc. The House Manager of this home stated they were not sure if these items were supposed to be locked or not. | An individual's records shall be kept locked when unattended.
| The kitchen contained two unlocked and unable to be locked file cabinets which contained current and previous individuals' personal information including their financial records, bank statements, individual support plan, were removed on 12/16/2022 with respect to regulation 6400.216a. See violation 10 attachment#41. |
12/16/2022
| Implemented |
| 6400.46(a) | Staff 4--6/22/21 Orientation fire safety training sign in sheet and curriculum were missing from the file. | 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 4 6/22/21 received a Site-Specific Orientation and fire safety training during their next scheduled workday on 12.24.2022. see violation 2 attachment#33. |
12/24/2022
| Implemented |
| 6400.52(a)(1) | Staff 4 has 21.25 training hours for the 5/20/21 through 5/19/22 training year, instead of the 24 hours required. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | As of 12.20.2022, staff 4 obtained 36.51 training hours for the 5.20.2022 ¿ 5.19.2023 training year. See violation 3 attachment#34. |
12/20/2022
| Implemented |
| 6400.52(c)(6) | Staff 4 has not received training in implementation of the individual plan for the 5/20/21 through 5/19/22 training year. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | Staff 4 completed ISP training for the individual she supports on 3/4/2022. The training record was discovered on 12/20/2022 as proof of completing this training. See violation 4 attachment#35. |
12/20/2022
| Implemented |
| 6400.169(a) | Staff 4's Medication training practicum last completed 5/15/21, only documentation of new practicum is observations checklist showing 2 observations done on 5/15/22. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | Staff #4 received additional medication practicum observation on 1/27/2023. See violation 9 attachment#40. The practicum observer was retrained to assure that all medication training practicum observations are completed according to regulation 6400.169(a) on 12/20/2022. See violation 9 attachment#40a. |
01/27/2023
| Implemented |