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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | On 1/15/25, at 1:22 PM, the light outside the exterior swing door of the attached garage was inoperable, and there was no other sufficient lighting sources located nearby. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| 66: Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
January 15, 2025- The maintenance supervisor replaced the light bulb. |
01/15/2025
| Implemented |
| 6400.101 | On 1/15/25, at 1:26 PM, the home's interior main water shut-off valve was enclosed, encompassing an area of two feet by three feet, four inches. However, the access panel door was equipped on the outside with two circular clasp locks that cannot be disengaged from inside the enclosure, therefore, creating an entrapment area or blocked egress. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| 101: Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
January 20, 2025- The maintenance supervisor removed the sliding latched lock from the door. |
01/20/2025
| Implemented |
| 6400.216(a) | On 1/15/25, at 1:42 PM, Individual #1's records, including demographic information, Individual Support Plan, medical information, financial information as well as their actual funds, were in plain view on an open shelf of a desk located in the home's living room. | An individual's records shall be kept locked when unattended.
| 216 (a): An individual¿s records shall be kept locked when unattended.
January 15, 2025- Residential staff #1 immediately locked up the individual personal records in a file cabinet in the home.
January 15, 2025- Residential staff #1 immediately removed the posted note that had the passcode information to the computer which has the electronic files of individual #1.
January 20, 2025- The maintenance supervisor replaced the lock on the staff office door with an electronic keypad to ensure personal files and information of individual #1 are protected. |
01/24/2025
| Implemented |
| 6400.15(b) | The agency used the Self-Inspection and Declaration Tool (modified June 2018) to measure and record compliance at the home on January 3, 2025, which does not contain all the elements on the current Department's licensing inspection instrument released on February 20, 2020. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | 15(b): The agency shall use the Department¿s licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulation to measure and record compliance.
January 20, 2025- The assessment was completed by the residential director using the latest required tool for community homes serving individuals with intellectual disabilities or autism, ensuring compliance with all elements of the Office of Developmental Programs within 6400 regulations. |
01/20/2025
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.106 | The home had a furnace inspection completed on 12/8/22 and then again on 12/28/23. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| On 6-26-2023 a new furnace was installed into the home, at that time of installation it was serviced and inspected. Then on 12/28/23 our agencies regular furnace technician cleaned and serviced the unit and completed the proper paperwork that it was complaint. However due to the new unit being installed it was not completed earlier by the technician. |
01/31/2024
| Implemented |
| 6400.110(f) | Individual #1 was born deaf. In the General Health and Safety Risks section of Individual #1's Individual Plan, last updated on 9/18/23 reads, "[Individual #1]'s house has a fire alarm that shakes her bed and has flashing lights to wake her." On 1/18/24 at 12:49PM, the smoke detectors were operable and equipped with flashing lights; however, the bed shaker was inoperable. | If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. | A new bed shaker was ordered and will be installed upon arrival to the agency by the maintenance coordinator. In the mean time the current system was serviced 1-18-24 and is operable. |
01/31/2024
| Implemented |
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