| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Poisons shall be locked or made inaccessible to individuals. Lysol sanitizers and room spray was located in the bottom cabinet inside the staff bathroom which was not locked at the time of inspection. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Poisons were secured at time of inspection. Staff on shift received immediate follow-up regarding the items that were unlocked. This consisted of re-training and disciplinary action. |
11/30/2024
| Implemented |
| 6400.62(c) | At the time of inspection there were 3 medicine cups filled with a green thick liquid in the medicine cabinet inside of the bathroom. The liquid was not able to be verified. Poisonous materials shall be stored in their original labeled container. | Poisonous materials shall be stored in their original, labeled containers. | Poisons were disposed of at time of inspection. Staff on shift received immediate follow-up regarding the items the issue. This consisted of re-training and disciplinary action. |
11/30/2024
| Implemented |
| 6400.64(a) | Clean and sanitary conditions shall be maintained in the home. At the time of inspection individual #1 bedroom was in disarray and very unsanitary. There was clothing scattered around the room, on the floor, and on the gaming chair in his bedroom. There was a bag full of unopened chips located inside of his closet as well as boxes of spaghetti on his dresser. There was garbage throughout the bedroom including empty soda cans under the bed. The pillow did not have proper linens on it and the pillow itself was very discolored and dirty. The windowsill contained spider webs and dust with small dead insects in the corner of the window. The walls were dingy and had liquid stains from an unidentifiable source. | Clean and sanitary conditions shall be maintained in the home. | Program Manager met with client to discuss concerns regarding the cleanliness of his room. Client agreed to let staff assist in cleaning. Room was cleaned and organized. |
11/30/1924
| Implemented |
| 6400.66 | At the time of the inspection the basement area had a side door which exits the outside of the home. This exit did not have a light on the exterior. Outside doorways, ramps, fire escapes shall be lighted to assure safety and avoid accidents. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Provider has contacted electrician and will be installing a light on the side of the location. Staff will monitor this light to make sure it is in good working order at all times. |
11/30/2024
| Implemented |
| 6400.67(a) | Walls and other surfaces shall be in good repair. The bathroom wall had what appeared to be a towel rack on the wall which was removed. The wall was not fully repaired to cover the holes in the wall at the time of inspection. | Floors, walls, ceilings and other surfaces shall be in good repair. | Provider has contacted maintenance to repair the wall. |
11/30/2024
| Implemented |
| 6400.67(b) | Surfaces shall be free from hazards. The upper kitchen cabinet to the right side of the stove had a broken shelf. The shelf poses a hazard as it is not fixtured to the cabinet and is lose to the touch allowing the shelf to fall through at any time. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Provider has contacted maintenance to repair the shelf. |
11/30/2024
| Implemented |
| 6400.104 | The home shall notify the local fire dept in writing of the address of the home, 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. At the time of the inspection there was not a current notice available. (repeat violation 9/13/23) | 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.
| All fire letters were collected for review. Letters will be reviewed for compliance and accuracy by the Quality Assurance and Regulatory Compliance Manager. This review will be submitted to the CEO by 11/15/24. |
11/30/2024
| Implemented |
| 6400.171 | Food shall be protected from contamination while being stored. At the the time of inspection there was several open bags of chips located inside the closet of individual #1 bedroom. These bags were not properly sealed or stored to prevent contamination. | Food shall be protected from contamination while being stored, prepared, transported and served.
| Items were discarded and staff were educated on proper food storage. |
11/30/2024
| Implemented |
| 6400.169(d) | A record of training shall be kept with the name of the person being trained, the date, the source, name of trainer and documentation that the course was successfully completed. Staff #1 had his initial medication administration training on 6.8.22. There was no documentation to reflect that staff #1 had completed the annual practicums as required. | A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed. | CEO (LC) met with training department to discuss citation and address ways to ensure that items and information are logged properly and accessible at request. Individual had Med Practicum but it was not properly reflected on the training record. |
11/30/2024
| Implemented |