| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | On 10/3/25 at 12:38 PM, on a shelf in a cabinet in the garage of the home, there was a clear, plastic spray bottle with a clear liquid inside that had the following written on it in marker: "Clorox Urine Remover (do not dilute)." | Poisonous materials shall be stored in their original, labeled containers. | The clear plastic bottle labeled "Clorox Urine Remover" was removed and thrown away. |
10/06/2025
| Implemented |
| 6400.67(a) | On 10/3/25 at 12:40 PM, the exterior, grade-level metal banisters--that provide security to the lower-grade, recessed exterior stairs leading to the home's basement from the garage and that are located on both sides these steps--were loose, non-sturdy and wobbled when in use. | Floors, walls, ceilings and other surfaces shall be in good repair. | Laurel House Inc Maintenance Team installed new/sturdy railing around the recessed stairs at the home.
Documentation/Pictures attached for review |
10/21/2025
| Implemented |
| 6400.67(b) | On 10/3/25 at 12:41 PM, there was a three-foot by five-foot area of water leaking from the ceiling and pooling onto the floor of the basement in the home. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Laurel House Maintenance Team went to the residential home but could not find a leak coming from the main floor of the home dripping into the basement. The basement floor is dry.
During the week of 10/27/25 to 10/31/25 DSPs at the home will complete a Home Hazard Checklist after Individual #1 showers or uses the restroom to see if water is leaking from the bathroom into the basement. After DSPs wash dishes, they will check to see if there is any water in the basement or if it is condensation build up on the pipes that would be creating any wet spots that were seen during licensing review.
Documentation/Pictures attached for review |
10/06/2025
| Implemented |
| 6400.70 | On 10/3/25 at 1:02 PM, the only home's only telephone was kept inaccessible and locked in the staff office. [Repeated Violation-11/13/24, et al] | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| DSP at the residential site moved the phone from the staff room to the kitchen of the home. The Emergency phone numbers which include: 911, poison control center, mental health crisis line, the local hospital, local police, state police, laurel house main office, and laurel house on call number, were also placed near the home.
Documentation submitted for review. |
10/22/2025
| Implemented |
| 6400.77(b) | On 10/3/25 at 1:00 PM, there was no tape in the home's first aid kit. [Repeated Violation-11/13/24, et al] | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | Laurel House Nursing Staff replaced the medical tape in the first aid kit located at the home.
Picture attached for review |
10/23/2025
| Implemented |
| 6400.81(j) | On 10/3/25 at 1:05 PM, there was no door or partition leading to Individual #1's bedroom. | A bedroom shall have doors at all entrances for privacy. | Laurel House, Inc Maintenance Team replaced the door to Individual #1 bedroom in the residential home.
Documentation attached for review. |
10/20/2025
| Implemented |
| 6400.81(k)(2) | On 10/3/25 at 1:06 PM, the mattress and box spring were directly on the floor with no bed frame in Individual #1's bedroom. Individual #1's Service Plan, last updated 5/27/25, does not include a restriction or preference for their bed's foundation. | In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. | It is unknown when the bedframe was removed from Individual #1s bedroom. It is documented in his Restrictive Plan that he has no preference to furniture in his bedroom. Program Supervisor/Specialist and his Behavioral Support Professional will speak with Individual #1 and his Legal Guardian to determine the best type of bed for him and Laurel House, Inc will have it ordered by 11/1/2025 |
11/01/2025
| Implemented |
| 6400.81(k)(6) | On 10/3/25 at 1:06 PM, there was no mirror in Individual #1's bedroom. | In bedrooms, each individual shall have the following: A mirror. | Shatterproof mirror tiles were ordered on 10/10/25 and were received and installed at Individual #1 home on 10/21/2025
Documentation provided for review |
10/21/2025
| Implemented |
| 6400.82(f) | On 10/3/25 at 12:54 PM, there was no mirror, soap, clean cloth or paper towels and trash receptacle in the bathroom of the hallway located near Individual #1's bedroom. [Repeated Violation-11/13/24, et al] | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Shatterproof mirror tiles were ordered on 10/10/25 and were received and installed at Individual #1 home on 10/21/2025
A new trash receptacle and shower caddies will be ordered for the individual to use during his shower times and bathroom times. |
11/26/2025
| Implemented |
| 6400.110(b) | On 10/3/25 at 1:13 PM, the closest smoke detector was located 27 feet, three inches away from the outside of Individual #1's bedroom door. | There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. | Laurel House, Inc Maintenance Team moved the smoke detector to less than 10 feet from the individuals bedroom. The smoke detector is now above the bathroom door which is right outside of the Individuals bedroom.
Documentation/Pictures attached for review. |
10/20/2025
| Implemented |
| 6400.111(c) | On 10/3/25 at 12:35 PM, there was no fire extinguisher in the kitchen of the home. | 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). | Laurel House, Inc Maintenance Team installed a fire extinguisher in the kitchen of the home.
Documentation submitted for review |
10/21/2025
| Implemented |
| 6400.111(f) | On 10/3/25, the fire extinguisher in the basement of the home was last inspected and approved by a fire safety expert in 1/2024. [Repeated Violation-11/13/24, et al] | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | Laurel House, Inc Maintenance Team installed a fire extinguisher in the basement of the home.
Documentation submitted for review |
10/21/2025
| Implemented |
| 6400.163(h) | On 10/3/25 at 12:51 PM, there was a box of CVS Health-brand Anti-Diarrheal tablets with an expiration date of 10/2024, located in the cabinet of the bathroom on the first floor of the home. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | The expired tablets were removed from the home. |
10/03/2025
| Implemented |
| 6400.186 | Individual #1 has a Restrictive Procedure Plan, that reads, "[Regarding] furniture: [Individual #1's] bedroom will contain only [their] bed. [Their] dresser and other furniture are stored in a locked room, to which [they] may request supervised access." On 10/3/25 at 1:05 PM, there was no doorknob on the door leading to the vacant bedroom where Individual #1's personal items are stored, preventing these items from being locked. Staff interviews revealed that the provider agency is currently following Phase Three of the fade plan. This fade plan reads, "Personal Items: Allow up to 60 minutes of independent time with items with routine checks." Therefore, the provider agency is not correctly implementing the Restrictive Procedure Plan. | The home shall implement the individual plan, including revisions. | On 10/21/25 a doorknob was installed on the bedroom that is utilized to store the individuals' personal belongings.
Laurel House, Inc Behavioral Support Team will review the individuals restrictive plan for accuracy and then schedule a team meeting to review the plan with all staff that work with the individual to ensure that the plan is being followed appropriately. |
11/26/2025
| Implemented |
| 6400.195(b) | Individual #1 has a Restrictive Procedure Plan implemented by the provider agency. The Human Rights Team completed reviews of Individual #1's Restrictive Procedure Plan on 9/17/24, and then again on 4/3/25. | 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. | The individuals' Restrictive Plan was reviewed on 9/25/2025 via Microsoft Teams with the Fayette Human Right's Coalition Team which would be in the allowable time frame of 6 months from 4/3/25 - 9/25/25. 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 |