| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(e) | At 11:14AM on 11/14/2024, a trash receptacle without a lid containing cardboard and other discarded items was in the garage of the home. | Trash receptacles over 18 inches high shall have lids. | Laurel House, Inc removed the receptacle that had no lid and replaced it with a compliant garbage can that had an attached lid. |
12/31/2024
| Implemented |
| 6400.67(b) | At 11:31AM on 11/14/2024, a three-inch by four-foot strip of carpet was missing leaving the tack strip exposed on the floor in Individual #1's bedroom posing a puncture wound hazard. At 11:32AM on 11/14/2024, a plastic bin with a broken lid with jagged pieces was on the floor in Individual #1's bedroom posing a laceration hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | On 12/3/24 Laurel House Inc, Maintenance Team went to the residential site and installed a new piece of carpeting over the exposed tack strip in Individual 1's bedroom. No
tacks were left exposed eliminating the wound hazard. The broken plastic bin in the individuals room was discharged and replaced with a new bin that was not broken. A photograph of repairs will be submitted to licensing for review. |
12/31/2024
| Implemented |
| 6400.74 | At 11:06AM on 11/14/2024, the three wooden exterior steps from back deck of the home did not have a nonskid surface. | Interior stairs and outside steps shall have a nonskid surface.
| On 12/3/2024 Laurel House, Inc Maintenance Team installed non-skid strips to the exterior deck stairs. Laurel House, Inc will submit a photograph of repairs completed at the residential site and documents to maintain compliance. |
12/31/2024
| Implemented |
| 6400.32(r)(1) | At 11:10AM on 11/14/2024, there was a pinhole lock on Individual #1's bedroom door. Individual #1 has not been provided with a mechanism to lock and 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. | On 12/3/24 Laurel House, Inc Maintenance Team replaced the doorknob on Individual #1's bedroom door to a key lock in order to give him access to lock or unlock his bedroom
door. Individual #1 has signed a key form stating that he would like a key to his room. Individual #1 received a key to his new lock and will practice using the key. The Program Supervisor/Specialist will have a discussion with Individual #1 about his privacy when his bedroom door is locked but the Direct Support Professionals working at this residential site will have a key to enter his bedroom in case of an emergency. The Program Supervisor/Specialist will also discuss with Individual #1 and DSPs in the home about what constitutes an emergency. Laurel House, Inc will submit a photograph of the corrected violation along with Individual rights and the key form. |
12/31/2024
| Implemented |
| 6400.32(r)(5) | At 11:10AM on 11/14/2024, there was a pinhole lock on Individual #1's bedroom door. Staff did not have a mechanism to lock and unlock the door. | Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door. | On 12/3/24 Laurel House, Inc Maintenance Team replaced the doorknob on Individual #1's bedroom door to a key lock in order to give him access to lock or unlock his bedroom
door. Individual #1 has signed a key form stating that he would like a key to his room. Individual #1 received a key to his new lock and will practice using the key. The Program Supervisor/Specialist will have a discussion with Individual #1 about his privacy when his bedroom door is locked but the Direct Support Professionals working at this residential site will have a key to enter his bedroom in case of an emergency. The Program Supervisor/Specialist will also discuss with Individual #1 and DSPs in the home about what constitutes an emergency. Laurel House, Inc will submit a photograph of the corrected violation along with Individual rights and the key form. |
12/31/2024
| Implemented |
| 6400.44(c)(2) | Program Specialist #1, date of hire 5/14/2024, did not have the work experience required for the program specialist position. | A program specialist shall have one of the following groups of qualifications: A bachelor's degree from an accredited college or university and 2 years of work experience working directly with individuals with an intellectual disability or autism. | On 11/14/2024 Laurel House, Inc assigned a qualified Program Specialist to oversee this home and a another home that Program Specialists #1 was overseeing. The newly assigned Program Specialist meets all qualifications to be a Program Specialist. Program Specialist one has been reassigned to a Program Supervisor and is also completing Quality Management and EIM Functions for Laurel House, Inc. Laurel House Inc will provide the qualified Program Specialists documentation for review to licensing. |
12/31/2024
| Implemented |
| 6400.163(d) | At 11:16AM on 11/14/2024, there were two single dose packets of Tylenol inside the first aid kit which was unlocked and accessible in the closet near the front door of the home. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | On 11/14/2024 Laurel House, Inc Nursing Coordinator, removed the single dose packets of Tylenol from the First Aid Kit. Laurel House, Inc nursing team completes monitoring visits to each of the residential homes. During these visits the first aid kits will be assessed for their content to ensure that needed supplies are there to maintain regulatory compliance. All DSPs working in the residential sites will notify the nursing department if supplies are needed for the kits. |
12/31/2024
| Implemented |