| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Clean and sanitary conditions are not maintained in the home. There were two rolls of fly paper hanging from the garage door openers in the garage that were completely covered with dead flies. | Clean and sanitary conditions shall be maintained in the home. | The fly paper cover in dead flies was immediately removed from the premises and there was no further evidence of flies. |
12/03/2024
| Implemented |
| 6400.111(c) | The home did not have an operable fire extinguisher located in the kitchen of the home. The fire extinguisher located in the kitchen of the home met the 2A-1-BC rating, however it was undercharged and no operable. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | The under-charged fire extinguisher was replaced on 12/5/24 by Cintas. Picture for verification sent via email. |
12/05/2024
| Implemented |
| 6400.32(r) | Individual #1's right to lock the individual's bedroom door was violated. Individual #1's Individual Service Plan stated "Individual #1's bedroom door does not have a lock. Individual #1 requested not to have a lock. There was no documentation to support that Individual #1 had been educated on the purpose of having a lock, informed consent, or the individual's right to lock the door at any time. | An individual has the right to lock the individual's bedroom door. | Individual #1 was educated on his rights and informed of his ability to have a locking mechanism on his door as seen in documentation via email. This occurred on upon admission on 3/22/24 and then again on 6/1/24. Individual #1 had a locking mechanism on his bedroom door with staff access to the key located in a common area. Individual #1 will have his pin lock door knob replaced with a keyed lock door knob with access to his key at all times should he choose to use it. Staff will also have access to the key at all times should it be needed in an emergency. |
01/31/2025
| Implemented |
| 6400.32(r)(1) | Individual #1 and Individual #2's bedroom doors had a pinhole lock that did not have an accessible key/tool available to access the lock. The lock on Individual #1 and Individual #2's bedroom door was not an acceptable entry device and there was no key/tool available to unlock the door. | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | The Doorknobs with the pin hole locking mechanism have been removed from the home and new door knobs were installed in their place. Individual #1 and #2 now have a key lock entry with a key available to them at all times should they choose to use it. |
01/31/2025
| Implemented |
| 6400.165(c) | Prescription medications are not administered as prescribed. Individual #1 is prescribed Flonase 2 sprays into each nostril once daily. The prescription contains 120 metered sprays. Use of 4 sprays per day equals a 30-day supply. The medication was filled on 10/22/24 and the bottle was almost a full bottle, indicating that the medication is not being administered as prescribed. | A prescription medication shall be administered as prescribed. | All staff who work with the individual who is prescribed the nasal spray will be re-trained on proper medication administration of the nasal spray and the importance of administrating medications as prescribed. |
01/08/2025
| Implemented |