| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | The individuals residing in the home have not been assessed to be safe with poisonous materials and a spray bottle of Formula 409 Multi-Surface Cleaner was found in an unlocked cabinet under the kitchen sink. The label on the bottle indicates that a Poison Control Center or medical doctor should be called if ingested. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The poisonous material was locked at time of discovery. IHRS Program Manager did provide direct feedback and disciplinary action to the staff that was on shift at the time. |
10/05/2025
| Implemented |
| 6400.64(a) | Clean and sanitary conditions shall be maintained in the home.
The inside floor of the oven and the door were heavily caked with burned on grease and food debris.
The front doors of the kitchen cabinets located near the stove were coated with a sticky film of dirt and grease.
The grouting around the bathtub/shower tiles was spotted with a black substance resembling mold or mildew. The caulking around the bathtub and shower walls was also spotted with a black substance resembling mold or mildew, and there was a black substance hanging from the faucet in the tub.
The grouting around the sink and vanity tiles in the bathroom hall was dirty with what appeared to be soap scum and mold or mildew.
There was a strong musty, stale smell in Individual #5's bedroom. | Clean and sanitary conditions shall be maintained in the home. | Program Manager directed staff to clean the oven. Oven was inspected to ensure that cleaning occurred. Direct feedback was provided to the site. |
10/05/2025
| Implemented |
| 6400.67(b) | Surfaces shall be free of hazards. The lint trap was full of lint at the time of inspection, creating a potential fire hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Provider has contacted maintenance to clean the dryer vent and lint trap. All of IHRS dryers are on a quarterly cleaning cycle. Staff were advised of the concern and trained on the possible fire hazard. A memo to the site and review of the issue during a staff meeting occurred. |
10/05/2025
| Implemented |
| 6400.80(b) | The outside of the building and the yard shall be well-maintained. There were insect webs and accumulated dirt and debris on the back door and siding at the rear of the home. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | Provider addressed areas of concerned identified during inspection. |
10/05/2025
| Implemented |
| 6400.112(h) | The fire drill records for the fire drills completed during the review period of September 2024 to August 2025 did not document whether all individuals met at the 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's and DSP's will be retrained on fire safety and fire drill requirements under Chapter 6400.112 (h). 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. All employees and consumers will be trained on meeting places for their respective sites. |
10/05/2025
| Implemented |
| 6400.171 | Food shall be protected from contamination while being stored, prepared, transferred and served. There was a plastic pitcher on the kitchen counter containing a beverage that appeared to be iced tea that was at room temperature and was not being stored under refrigeration. | Food shall be protected from contamination while being stored, prepared, transported and served.
| IHRS disposed of item believed to be ice tea. Staff was re-trained in proper food storage. |
10/05/2025
| Implemented |
| 6400.46(d) | Staff #3 is functioning as the Agency's Program Specialist and has not been trained by a hospital or other recognized health care organization in first aid, Heimlich techniques and cardiopulmonary resuscitation. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | IHRS had previously issued discipline to the aforementioned staff for not meeting regulatory requirements with training. Training policy was enforced. |
10/05/2025
| Implemented |
| 6400.52(c)(5) | Staff #3 is functioning as the Agency's Program Specialist and did not complete training in the safe and appropriate use of behavior supports during the training year 1/01/2024 through 12/31/2024. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | Training was assigned to staff #2 and completed. |
10/05/2025
| Implemented |