| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | At 10:14 AM on 11/14/2024, the interior ceiling of the microwave contained several dried white and yellow colored food splatters. | Clean and sanitary conditions shall be maintained in the home. | On 12/14/24, Laurel House, Inc DSPs in the home were instructed by the homes Program Supervisor/Specialist to clean out the microwave in order to maintain sanitary conditions in the home. Laurel house, Inc will submit a photograph of the correction to licensing for review. |
12/31/2024
| Implemented |
| 6400.82(f) | At 10:34 AM on 11/14/2024, there were no individual clean paper or cloth towels in the accessible bathroom in the bedroom hallway on the home's main level. | 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. | Laurel House, Inc DSPs working at the home made sure to place clean cloths in the bathroom so that it was accessible to all individuals of the home to use. Laurel House, Inc also has a contract with UniFirst to supply paper towel and toilet paper to all of our residential homes. Program Supervisors/Specialists and DSPs are all trained during their orientation of accessibility of paper products in the home and also sanitary conditions for washing cloths used in the home. |
12/31/2024
| Implemented |
| 6400.110(e) | At 11:00 AM on 11/14/2024, the smoke detectors of this three-story home were not interconnected. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | The current smoke detectors in the home are currently interconnected, staff were not aware of how long they needed to hold in the test button to make all of the detectors beep. According to the Fayette property website, 245 Balsinger is a one-story home with a basement.
Program Supervisors/Specialists of the home will make sure that all staff working in the home are trained on how to correctly operate the fire/smoke detector system, which will be used monthly during all fire drills at the home. Any issues or concerns with the detector system will be reported to the Program Supervisor/Specialist who will complete a Maintenance Request for Repairs to have the system looked at. A picture of the detection system will be sent to licensing for review along with the fire drill form . |
12/31/2024
| Implemented |
| 6400.141(c)(11) | Individual #1's initial physical examination, completed 4/16/24, did not include an assessment of the individual's health maintenance needs and the need for bloodwork at recommended intervals. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | Laurel House, Inc uses the approved physical form for 6400 Services. Individual #1's physical was updated on 12/2/2024 to reflect the above reflected information. |
12/31/2024
| Implemented |
| 6400.181(e)(6) | Individual #1's assessment, completed 6/1/24, provided a "Score of 1," indicating Individual #1 requires heavy physical guidance to safely use poisonous materials, and a "Score of 3," indicating Individual #1 can avoid poisonous materials, independently. | The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | Laurel House, Inc Program Supervisor/Specialist submitted the Annual Assessment to the Fayette Co SCO/SC for Individual #1 in order to be updated in the individuals ISP. |
12/31/2024
| Implemented |
| 6400.32(r)(1) | At 10:10AM 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. At 10:12AM on 11/14/2024, there was a pinhole lock on Individual #2's bedroom door. Individual #2 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 12/4/2024 Laurel House, Inc Maintenance Department the pinhole locks on Individual #1 and Individual #2s doors. A standard door handle with no locking mechanism was used. A photograph of the correction will be submitted to licensing for review. Individual rights and also Key Agreement Forms are reviewed with all individuals upon Admission to Laurel House, Inc. Forms are kept in individuals files regarding their choice of wanting to lock their bedrooms or have a key if they choose to lock the door. A copy of Individual Rights and Locking and Key Access forms will be submitted to Licensing for review along with pictures of the updated doorknobs of the Individuals rooms. |
12/31/2024
| Implemented |
| 6400.32(r)(5) | At 10:10AM 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. At 10:12AM on 11/14/2024, there was a pinhole lock on Individual #2'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 12/4/2024 Laurel House, Inc Maintenance Department the pinhole locks on Individual #1 and Individual #2s doors. A standard door handle with no locking mechanism was used. A photograph of the correction will be submitted to licensing for review. Individual rights and also Key Agreement Forms are reviewed with all individuals upon Admission to Laurel House, Inc. Forms are kept in individuals files regarding their choice of wanting to lock their bedrooms or have a key if they choose to lock the door. These are kept on file in the individuals charts at Laurel House, Inc, If an individual chooses that they want a lock on their door a key will be provided to them as well as staff. Staff would be instructed on proper use of using the key on in emergencies or if the individual requests them to use it. Staff at Laurel House Inc also have a key receipt form when they receive any keys for the home, which is provided to them by the Maintenance Team. In this case no locks are on the individuals doors and no keys are required to be given to staff. A copy of the they form will be sent to licensing for review. |
12/31/2024
| Implemented |
| 6400.163(d) | At 10:22 AM on 11/14/24, there were two single dose packets of Tylenol inside the first aid kit which was unlocked and accessible in 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 Nursing Staff removed the Tylenol Packets from the first aid kit. 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 |