| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.63(a) | At 11:45 AM on 10/3/25, the hot water temperature at the kitchen sink measured 123.2 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. |
10/08/2025
| Implemented |
| 6400.64(a) | At 11:46 AM on 10/3/25, the interior of the oven's base was covered in blackened grease and food particles, and its sides and back end were coated in a white chalky substance, appearing to be residue from a cleaner. In addition, the base of the air fryer tray contained food particles, including two cooked French fires. At 12:08 PM, the interior of the freezer located in the basement contained food crumbs. The top shelf inside the corresponding refrigerator was lined with white, dried-up liquid spills and food particles as well as underneath the lower left crisper drawer, which was coated with a reddish liquid spill. | Clean and sanitary conditions shall be maintained in the home. | After licensing inspectors left the residential site on 10/3/25, the DSP working in the home cleaned the oven, air fryer, freezer, and refrigerator.
Documentation/pictures provided for review. |
10/03/2025
| Implemented |
| 6400.67(b) | At 11:58 AM on 10/3/25, on the sill of the only window in Individual #2's bedroom were six sheet metal screws with sharp, pointed tips. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The screws were taken off the windowsill on 10/3/25 and brought to the Laurel House Main Office. |
10/03/2025
| Implemented |
| 6400.101 | At 12:13 PM on 10/3/25, the interior side of the attached garage's swing door leading to the outside was equipped with two sliding latch locks as well as its exterior, which was equipped with one sliding latch lock. The interior door leading from the basement was equipped with a lock, requiring a key to disengage it from the garage side. Therefore, an entrapment area existed within the attached garage. [Repeated Violation-11/13/24, et al] | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Laurel House Inc Maintenance Department removed the sliding latch locks from the interior and exterior of the garage swing door. Maintenance replaced the key locks on the garage seing door to the home and the garage wing door to the outdoors. One key locks and unlocks both man doors. From inside the garage, if the swing door to enter the home is locked, one can still exit the garage via the other sing door because it does not require a key from the inside of the garage.
Documentation Provided for Review |
10/22/2025
| Implemented |
| 6400.141(c)(12) | Individual #1's current physical examination, completed on 6/25/25, 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 6/25/25, 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 |
| 6400.181(e)(12) | Individual #1's date-of-admission is 5/1/25. Their initial and current assessment, completed on 5/7/25, listed the following recommendations: "Take prescribed medications; go to all doctor appointments; keep personal space clean; control vocal disruptions; and bathe daily." However, this assessment did not include specific areas of training, programming, and services to foster Individual #1's skill growth and development in these recommended areas. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The Program Specialist for the individuals home was notified that the assessment needs to be more specific in areas where it is documented that the individual will "complete, practice, or learn things". 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 12:20 PM 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; 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, and psychological evaluation. |
11/26/2025
| Implemented |
| 6400.182(c) | Individual #1's Service Plan, last updated 9/17/25, contained the following discrepancies between their initial and current assessment, completed on 5/7/25, in the following health and safety skill domain: regarding home supervision, Individual #1's Service Plan, last updated 9/17/25, stated Individual #1 requires 20 hours of supervision and "is able to be alone for up to four hours." However, Individual #1's assessment, completed on 5/7/25, indicated that Individual #1 can be left unsupervised for 24 hours a day; and regarding community supervision, Individual #1's Service Plan, last updated 9/17/25, explained the following: that Individual #1 requires 20 hours of supervision; that they are able to be alone for up to four hours; that "[Individual #1] can cross both rural and urban streets, [as] [they] frequently take walks to and from a variety of places within the community and practice proper safety skills when doing so." In contrast, Individual #1's assessment, completed on 5/7/25, informed that Individual #1 can be left unsupervised in the community for 24 hours and that they can independently cross streets. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The individual's Program Supervisor/Specialist will complete an update to the individual's assessment. This error occurred when the individual moved from independent living/IHCS to Residential Services on 5/1/25. Once the Assessment is revised, a copy will be sent to the individuals Supports Coordinator and a copy will be saved in the individuals chart located at the Laurel House Inc Main Office and the Individuals Home. |
11/05/2025
| Implemented |