| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | On 10/3/25 at 11:17 AM, a container of Ortho Home Defense Insect Killer Spray was on the floor directly next to bags of potato chips, tortilla chips and bottles of flavored water as well as juice in the closet of the staff office located on the first floor of the home. | Poisonous materials shall be stored in their original, labeled containers. | On 10/3/25, the Ortho Home Defense Insect Spray was removed from the staff room and placed in the cabinet that contains other potentially poisonous substances. |
10/03/2025
| Implemented |
| 6400.72(a) | On 10/3/25 at 11:15 AM, there was a one-half-inch gap between the air conditioner and the window frame on the left side and a one-inch gap between the air conditioner and the window frame on the right side in the staff office located on the first floor, allowing space for insects to enter the home. At 11:52 AM, there was a one and one-half-inch gap between the air conditioner and the window frame on the left side and a one-half-inch gap between the air conditioner and the window frame on the right side in Individual #1's bedroom, allowing space for insects to enter the home. [Repeated Violation-11/13/24, et al] | Windows, including windows in doors, shall be securely screened when windows or doors are open. | All window air conditioning units were removed from the residential site on 10.20.25. |
10/20/2025
| Implemented |
| 6400.72(b) | On 10/3/25 at 11:56 AM, there was an inordinate amount of holes in the screen of the window in the vacant room located to the right of the bathroom on the second floor of the home. [Repeated Violation-11/13/24, et al] | Screens, windows and doors shall be in good repair. | Laurel House, Inc Maintenance Team replaced the window screen at the home. |
10/20/2025
| Implemented |
| 6400.80(b) | On 10/3/25 at 11:37 AM, there was a bush overgrown approximately one foot onto the bottom landing of the exterior stairs located on the right side of the home. At 11:38 AM, there was a two-by-four block of wood bolted to each side of the double-sided railing along the concrete, exterior stairs located in the back of the home. The brick and mortar attaching the stairs and the concrete landing were cracked and separating, appearing unsafe to walk on. Additionally, there were eight exterior, concrete stairs attached to the same landing with cracked, separating bricks and concrete. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | Laurel House Inc Maintenance Team removed the overgrown bush that was located at the bottom of the outdoor landing of the home (10/20/25). Maintenance received a project bid for the concrete work that needs to be completed at the home. A copy of the bid has been attached for review. Upon selecting the contractor and a date to begin the renovation project, the stairs, railing, and concrete landing shall be repaired. |
10/06/2025
| Implemented |
| 6400.101 | On 10/3/25 at 12:02 PM, there was a slide chain lock on the inside of the door in the basement. [Repeated Violation-11/13/24, et al] | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Laurel House, Inc Maintenance Team removed the slide chain lock from the basement door. |
10/22/2025
| Implemented |
| 6400.104 | The provider agency sent a notification letter to the local fire department on 10/29/2024 that reads, "all of the individuals are ambulatory and can evacuate with minimal assistance." However, this letter did not provide the exact location of the individuals' bedrooms. | 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.
| Laurel House, Inc is currently getting layout designs of all residential sites that will accurately show where bedrooms are located in the homes. Once all updated information is obtained, New Fire Department letters will be mailed out that contain maps of the residential sites with bedroom locations and exits clearly marked. |
11/26/2025
| Implemented |
| 6400.181(e)(12) | Individual #1's current assessment, completed 10/3/25, did not include recommendations for specific areas of training, programming and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Upon review of Individual #1 Assessment, it is dated 10/3/24. The Assessment due prior to the individual's Annual ISP will be completed by 10/30/24. The Program Specialist for the individuals home was notified that the assessment needs to be more specific in areas where it is documented that the individual will "complete, practice, or learn things". Regulatory Compliance Recommendations for completing the assessment were reviewed with the Program Specialist on 10/22/25. |
11/05/2025
| Implemented |
| 6400.32(d) | On 10/3/25 at 12:06 PM, there was a sign posted on the wall directly to the right of the front door that read, "No Phone Zone. [Individual #1] to keep you safe in the home and in the community your phone is not permitted past this point. No phone in the bathroom!!! No phone upstairs!!! No phone on outing!!! No phone at Family Ties!!! Use your phone only in approved areas. Ask staff if you are not sure. Thank you for following the rules!!!" | An individual shall be treated with dignity and respect. | After learning of the violation, Laurel House Inc began a Certified Investigation for a right's violation/unauthorized restrictive procedure. Laurel House Inc DSP working at the home removed the sign from the front area of the home. The individual's health and safety was ensured by doing a wellness check on her. Behavioral Support Staff were aware of the sign and stated they posted the sign after the individual said she wanted the sign since it reminded her of the procedures for her phone use. Behavioral Specialist and individual will discuss a more appropriate place for her to hang her sign, i.e inside of her bedroom door, which she will see every day to remind her of her phone usage. |
10/03/2025
| Implemented |
| 6400.32(r)(1) | On 10/3/25 at 11:15 AM, there was a keyed locking mechanism on the outside and a turn locking mechanism on the inside of the door leading to Individual #2's bedroom. Individual #2 has not been provided with a key to lock and unlock the door independently. [Repeated Violation-11/13/24, et al] | 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. | Individual #2 Admission Paperwork was reviewed to determine if the Individual Rights-Key Possession-Residential Form had been completed and if keys were requested for her bedroom and main door to her home. The Individual did not wish to have a key/lock to her bedroom or a key to the home. Laurel House Maintenance Team removed the key lock entry to Individual #2 bedroom and replaced it with a regular doorknob.
Pictures and Maintenance Request Attached for review. |
10/22/2025
| Implemented |
| 6400.32(r)(4) | On 10/3/25 at 11:15 AM, there was a keyed locking mechanism on the outside and a turn locking mechanism on the inside of the door leading to Individual #2's bedroom. Staff's key to Individual #2's bedroom door was not labeled, and Individual #2 has not been provided a key, therefore, preventing easy and immediate access by Individual #2 and staff in the event of an emergency. | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. | Individual #2 did not wish to have a key or locking mechanism to her bedroom, per her Key Possession form that was signed on 1/3/25. Laurel House Maintenance replaced the doorknob to her room with a regular doorknob and took the key that was on residential staff's keys. |
10/22/2025
| Implemented |
| 6400.46(a) | Program Specialist #1 was trained in fire safety on 5/16/24, and then again on 6/9/25. | 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. | Laurel House, Inc is currently working with Jessica Washowich from Keystone Management in order to provide Laurel House Inc Program Staff with up-to-date training from a Fire Safety Expert. A Fire Safety Training has been schedule for 11/10/2025 by Jamie Pergola, a Certified Safety Professional. Jamie will train all Program Supervisors/Specialists on 11/10/2025 |
11/10/2025
| Implemented |
| 6400.195(b) | Individual #1 has a Restrictive Procedure Plan implemented by the provider agency. Individual #1's Restrictive Procedure Plan was last reviewed by the Human Rights Team on 10/3/24. | The behavior support component of the individual plan shall be reviewed and revised as necessary by the human rights team, according to the time frame established by the team, not to exceed 6 months between reviews. | Laurel House Inc Behavioral Specialist, pulled the 2/5/21 ODP Bulletin on Guidance for Human Rights teams and Human Rights Committees for review. Behavioral Supports along with Laurel House Program Director and CEO are developing a Human Rights Team/Committee to review Restrictive Procedures on a quarterly basis. Until the Laurel House Human Rights Team is developed, HRT meetings will continue to be scheduled with ARC Fayette. The next HRT Meeting is scheduled for 10/24/2025 |
11/26/2025
| Implemented |