| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.63(a) | At 10:31 AM on 10/3/25, the hot water temperature at the kitchen sink on the home's main level measured 129.0 degrees Fahrenheit. | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | On 10/8/2025 Laurel House Maintenance Team went to the residential site and adjusted the temperature of the hot water tank to within a regulatory temperature.
Documentation/Pictures submitted for review |
11/26/2025
| Implemented |
| 6400.112(c) | According to the written fire drill record submitted from 10/11/24 to 9/17/25, the drill conducted on 8/29/25 did not include the time it took to evacuate, as the corresponding field was left blank on the form. [Repeated Violation-11/13/24, et al] | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | For the October 2025 residential monthly fire drill Program Supervisor/Specialist and the Program Director or Assistant Program Director will review the completed fire drill form for accuracy. |
11/26/2025
| Implemented |
| 6400.113(a) | Individual #1 completed fire safety training on 1/29/24, and then again on 1/29/25. On 10/2/25, the agency stated that fire drills are conducted at the homes as part of the individuals' fire safety training to incorporate location-specific requirements. However, according to the written fire drill record submitted from 10/11/24 to 9/17/25, a drill was not conducted on 1/29/25. Therefore, Individual #1's fire safety training, completed on 1/29/25, did not include location-specific content. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually 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 and smoking safety procedures if individuals smoke at the home. | 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 |
| 6400.141(c)(12) | Individual #1's current physical examination, completed on 10/22/24, did not address physical limitations, as the corresponding field was left blank on the form. | The physical examination shall include: Physical limitations of the individual. | Prior to any individual attending a scheduled physical exam, the Laurel House Nursing Team will complete any sections of the physical that they can complete prior to sending the form with the individual to their appointment. |
11/01/2025
| Implemented |
| 6400.141(c)(15) | Individual #1's current physical examination, completed on 10/22/24, did not address special instructions for their diet, as the corresponding field was left blank on the form. | The physical examination shall include:Special instructions for the individual's diet. | Prior to any individual attending a scheduled physical exam, the Laurel House Nursing Team will complete any sections of the physical that they can complete prior to sending the form with the individual to their appointment. |
11/01/2025
| Implemented |
| 6400.144 | At 11:04 AM on 10/3/25, agency interviews informed that Individual #1 was out in the community to Ohio Pyle with Direct Service Provider #1. However, agency interviews also revealed that Direct Service Provider #1 did not have Individual #1's prescribed, life-sustaining pro re nata medication, Albuterol HFA Inhaler---Inhale 2 puffs by mouth every 4 hours as needed for shortness of breath/ wheezing---for their asthma diagnosis in the case of an emergency while out in the community. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Laurel House Inc. Nursing Coordinator obtained a lock box to hold Individual#1 Inhaler. DSPs working at the home have been trained of the importance of taking the individuals inhaler and lockbox with them on all outing in the community.
Documentation/pictures provided for review. |
11/26/2025
| Implemented |
| 6400.171 | At 10:34 AM on 10/3/25, the following food items in the upper kitchen cabinet located next to the sliding glass door near the bathroom on the home's main level were open, unsealed, and unprotected from contamination: a one-pound cereal box of Honey Nut Cheerios; and a one-pound, 30.8-ounce cereal box of Strawberry Vanilla Chex. [Repeated Violation-11/13/24, et al] | Food shall be protected from contamination while being stored, prepared, transported and served.
| All Laurel House, Inc Residential Sites will have bag clips and/or plastic food storage containers ordered for all cereals to be stored in. Storage containers and/or clips will be in the homes for any other food items that are in bags so they can be stored appropriately. |
11/26/2025
| Implemented |
| 6400.181(e)(4) | Individual #1's current assessment, completed on 6/6/25, did not address their supervision needs in both the home and community, as the document did not contain any reference to or language regarding this health and safety domain. | The assessment must include the following information: The individual's need for supervision.
| The Program Specialist for the individuals home was notified that the assessment needs to be fully completed and detailed. Regulatory Compliance Recommendations for completing the assessment were reviewed with the Program Specialist on 10/22/25. During the Laurel House, Inc Program Specialist Bi-weekly meeting scheduled for 11/5/25, Assessments and Regulatory Compliance Recommendations for Assessments will be reviewed with the Program Supervisors/Specialists so that they will understand to enter more detailed information regarding training, programming, and services for individuals. |
11/05/2025
| Implemented |
| 6400.181(e)(14) | Individual #1's current assessment, completed on 6/6/25, did not address their ability to swim, as the corresponding health and safety skill domain indicated a score of "3," meaning that Individual #1 can independently regulate their own water temperature, and added only that "[Individual #1] would have a life jacket." (Consequently, Individual #1's Service Plan, last updated 9/19/25, left Individual #1's ability to swim unaddressed as well.) | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | The Program Specialist for the individuals home was notified that the assessment needs to be fully completed and detailed. Regulatory Compliance Recommendations for completing the assessment were reviewed with the Program Specialist on 10/22/25. During the Laurel House, Inc Program Specialist Bi-weekly meeting scheduled for 11/5/25, Assessments and Regulatory Compliance Recommendations for Assessments will be reviewed with the Program Supervisors/Specialists so that they will understand to enter more detailed information regarding training, programming, and services for individuals. |
11/05/2025
| Implemented |
| 6400.214(b) | At 10:46 AM on 10/3/25, neither hard nor electronic copies of the following regarding Individual #1's most current records were kept at the home: a current, dated photograph; a Service Plan, last updated 5/14/25 (Service Plan in HCSIS was last updated 9/19/25); an applicable behavior support plan; an applicable restrictive procedure plan; and an applicable psychological evaluation. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| Laurel House Inc Program Supervisor/Specialist will update client's chart at the residential site with an updated photo, current HCSIS Individual Support Plan, Behavioral/Restrictive Plan, and psychological evaluation. |
11/26/2025
| Implemented |