Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00256059 Renewal 11/13/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)At 1:09PM on 11/14/2024, a plastic spray bottle of Windex, a gallon of Clorox Bleach, a bottle of Lysol, a spray bottle of Mr. Clean Bathroom cleaner and a spray bottle of Clorox All Purpose Cleaner were unlocked and accessible in the cabinet under the sink in the kitchen of the home.Poisonous materials shall be kept locked or made inaccessible to individuals. On 12/6/2024 Laurel House, Inc Maintenance Team went to the residential site to ensure that a lock was on he cabinet where all poisonous substances/cleaning supplies are kept to make sure that they are inaccessible to the individuals. Laurel House, Inc will submit photograph of locked cabinet door. 12/31/2024 Implemented
6400.67(b)At 1:39PM on 11/14/2024, the metal lift rod connected to the faucet on the sink in bathroom on the first floor of the home was broken exposing jagged edges on each end posing a laceration hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.Laurel House Inc, Maintenance Team went to the residence and replaced the lift rod stopper in the first-floor bathroom. 12/04/2024 Implemented
6400.73(a)At 1:32PM on 11/14/2024, the six outside concrete steps on the side of the home, did not have a railing. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. On 12/10/2024 Laurel House, Inc Maintenance team installed new aluminum post on the right side of the outdoor stairs with a handrail/ Solar illuminating lights were also added to make sure that the steps can be seen in the dark. DSP's working in the home will ensure that the handrails are in good working order and report to the Program Supervisor/Specialist if repairs are needed. Repairs will be entered on a maintenance request form. Program Supervisors/Specialists visit the homes weekly. Monthly they will also complete a home hazard/safety checklist and report if any repairs are needed. 12/31/2024 Implemented
6400.80(a)At 1:32PM on 11/14/2024, three of the six outside concrete steps on the side of the home were covered in leaves and vines, posing a slipping, tripping, and falling hazard. Outside walkways shall be free from ice, snow, obstructions and other hazards. On 12/10/2024 Laurel House, Inc Maintenance Team went to the home to repair the railing on the steps. During this visit they also cleared the steps of all leaves and vines that posed a tripping/fall hazard to individuals at the home. Program Supervisors/Specialists complete weekly visit forms and also do a Monthly Home Hazard/Safety Checklist of the home. DSPs at the home will check all outdoor steps and railings to ensure that they are free of and trip/fall hazards 12/31/2024 Implemented
6400.83(c)At 1:11PM on 11/14/2024, a plastic container of used cooking oil with food particles inside was in the cabinet under the counter in the kitchen of the home. At 1:13PM on 11/14/2024, an uncovered bowl of partially eaten ice cream with a spoon frozen inside the ice cream was in the freezer in the kitchen of the home.Utensils used for eating, drinking and preparation of food or drink shall be washed and rinsed after each use.The plastic container of oil was disposed of and the ice cream bowls and spoons found during inspection were emptied and cleaned by the DSPs working on the day of inspection, 11/14/24. During a weekly Program Supervisor/Specialist home visit, DSPs working in the home were educated on regulatory Compliance Regarding Kitchens and washing dishes and utensils that have been used in the home to prevent the spread of diseases. 12/31/2024 Implemented
6400.171At 1:11PM on 11/14/2024, a plastic container of used cooking oil and food particles was in the cabinet under the counter in the kitchen of the home. At 1:13PM on 11/14/2024, two uncovered bowls of partially eaten ice cream were inside the freezer in the kitchen of the home.Food shall be protected from contamination while being stored, prepared, transported and served. The plastic container of oil was disposed of and the ice cream bowls and spoons found during inspection were emptied and cleaned by the DSPs working at the home on the day of inspection, 11/14/24. During a weekly Program Supervisor/Specialist home visit, DSPs working in the home were educated on regulatory Compliance Regarding Kitchens and washing dishes and utensils that have been used in the home to prevent the spread of diseases and how to properly protect food from contamination while being stored. 12/31/2024 Implemented
6400.195(a)At 1:32PM on 11/14/2024, Individual #1 did not have a chest of drawers and access to clothing in Individual #1's bedroom. Staff interviews revealed that Individual #1's personal items are kept in another closet due to behavioral issues. Individual #1 does not have a Restrictive Procedure Plan.For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures.Individual #1 has his clothing kept in a separate room in the home for him to go to, to choose what outfits he would like to wear daily. Individual #1 likes to take his clothing and tie them together to make a whip. Program Specialist and DSPs in the home hung clothing up in Individual #1s closet. The Program Specialist met with BLT Behavioral Supports on 12/5/24 to inquire about a referral for behavioral supports. Laurel House, Inc is waiting to hear back from BLT regarding services for Individual #1 for Behavioral Supports. The Program Specialist for the home ordered Individual #1 a small chest of drawers for him to keep in his room for his clothing until Behavioral Supports Provide the individual and Laurel House, Inc with information regarding behavioral supports for Individual #1. Individual Rights are reviewed with all individuals upon admission to Laurel House, Inc. For any individual who presents with or displays any maladaptive behavior, a referral to behavioral supports will be completed. All behavioral plans with be reviewed and staff working with individuals will be trained on behavioral and any restrictive plans that would be put in place for them. 12/31/2024 Implemented
SIN-00215966 Renewal 12/06/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(f)The front door was used as the exit route for the fire drills held from 1/30/2022 to 11/3/2022. The home has three exits.Alternate exit routes shall be used during fire drills. Laurel House staff conducted a fire drill on 12/08/2022 at 3:07 pm. The exit route used was the side door for a hypothetical fire location of the kitchen. A copy of the fire drill is included in the Plan of Correction. 12/08/2022 Implemented
6400.181(e)(2)Individual #1's assessment, completed 7/28/22 did not include the likes and dislikes of the individual.The assessment must include the following information: The likes, dislikes and interest of the individual. The Individual's (BO) assessment page of likes/dislikes/interests was completed on 12/6/2022 to comply with the above regulation. The assessment sheet was placed in BH's record by Program Specialist, Sarah Sullivan. A copy of the assessment sheet will be provided with the Plan of Correction 12/06/2022 Implemented
6400.182(a)Individual #1's assessment, completed 7/28/22 reads that Individual #1 cannot sense and quickly move away from dangerous heat source. Individual #1's Individual Plan, last updated on 11/10/22, indicates Individual #1 avoids dangerous heat sources.The program specialist shall coordinate the development of the individual plan, including revisions with the individual and the individual plan team.The Program Specialist spoke with the SC for her to do a general ISP update that reflects the needs of Individual #1. Individual #1 also has an annual ISP meeting on 1/4/23 where all of his needs will be discussed. 12/19/2022 Implemented
SIN-00182848 Renewal 02/08/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(e)(1)The assessment completed 09/25/20 for Individual #1 did not include strengths, needs, or preferences of the individual. This section was left blank. The assessment must include the following information: Functional strengths, needs and preferences of the individual. Strengths, needs, and Preferences were completed in the assessment for individual #1 by the program specialist on 2/15/21 to 2/16/21. Going forward, after the assessment is completed and signed by the program specialist, the assessment will be reviewed by the program director to ensure that all areas of the assessment are completed in their entirety. Training in regulation 6400.181(e)(1) was given to all program specialists by the program director as well as the staff. It is the opinion of the program director that staff should be aware of the importance of a complete assessment. Supporting documentation attached. 02/12/2021 Implemented
6400.181(e)(2)The assessment, completed 09/25/20 for Individual #1 did not include likes, dislikes, or interests of the individual. This section was left blank.The assessment must include the following information: The likes, dislikes and interest of the individual. Likes, Dislikes, or Interests of the Individual were completed in the assessment for individual #1 by the program specialist on 2/15/21 to 2/16/21. Going forward, after the assessment is completed and signed by the program specialist, the assessment will be reviewed by the program director to ensure that all areas of the assessment are completed in their entirety. Training in regulation 6400.181(e)(2) was given to all program specialists by the program director as well as the staff. It is the opinion of the program director that staff should be aware of the importance of a complete assessment. Supporting documentation attached. 02/12/2021 Implemented
6400.34(a)Individual #1 was informed and explained individual rights on 1/13/2021. The rights document did not include the following rights: 6400.32d, to be treated with dignity and respect; 6400.32e, the right to make choices and accept risks; 6400.32f to refuse to participate in activities and services; 6400.32g, to control his own schedule and activities; 6400.32h, to control his own schedule and activities; 6400.32l, to receive scheduled and unscheduled visitors and to communicate and meet privately with whom the Individual chooses, at any time; 6400.32q, to furnish and decorate the Individual's bedroom and the common areas of the home; 6400.32r, to lock the Individual's bedroom door; 6400.32s, to have a key, access card, key code or other entry mechanism to lock and unlock an entrance door of the home; 6400.32t, to access food at any time; 6400.32u, to make health care decisions; 6400.32v, right may only be modified accordance with 6400.185.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.ndividual #1 was informed of the revised rights on 2/12/2021 by the staff and program specialist. These individual rights were immediately corrected by the program director and were reviewed with the staff and program specialist. These rights will be reviewed with the individual with staff assistance. After completion they will be reviewed by the program specialist and program director for signature to ensure that the correct set of rights are received by the individual and that they were completed within the annual timeframe. Staff were trained on regulation 6400.34(a). Supporting documentation attached. 02/12/2021 Implemented
6400.181(f)The program specialist provided the assessment, completed 9/25/20 for Individual #1 to the individual plan team members on 09/25/20 for the individual plan meeting on 10/22/20.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.When the support coordinator proposes a date for the annual ISP meeting that is less than 30 days following an assessment notification, the program specialist will check the date of assessment and request to change the meeting date to comply with the regulation and ensure that the meeting is held at least 30 days after the assessment notification date. The program director will communicate with Fayette County Behavioral Health Administration Director of Intellectual Disabilities, the importance of regulation 6400.181(f). Supporting documentation attached. 02/18/2021 Implemented
SIN-00234793 Renewal 11/15/2023 Compliant - Finalized
SIN-00198372 Renewal 01/04/2022 Compliant - Finalized
SIN-00164028 Renewal 10/08/2019 Compliant - Finalized
SIN-00144564 Renewal 10/31/2018 Compliant - Finalized
SIN-00124742 Renewal 11/14/2017 Compliant - Finalized