| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(b) | On 1/15/25, at 12:31 PM, the bottom right corner of the screen in the only window located in the staff office had a tear in the shape of a square, measuring three-quarters of an inch by three-quarters of an inch. | Screens, windows and doors shall be in good repair. | 72 (b): Screens, windows, and doors shall be in good repair.
January 20, 2025 ¿ The maintenance supervisor repaired the screen in the window by patching the hole.
The maintenance supervisor checked to ensure the hole was completely sealed. |
01/20/2025
| Implemented |
| 6400.101 | On 1/15/25, at 12:01 PM, the interior door leading from the laundry room to the attached garage was equipped with a sliding-latch lock facing the laundry room and a deadbolt lock requiring a key to disengage it from the garage side. Therefore, an entrapment area or blocked egress exists. On 1/15/25, at 12:05 PM, the exterior door leading from the laundry room to the back porch was equipped with a standard doorknob lock assembly and deadbolt, and in addition, with two sliding-latch locks, one at the top and one at the bottom, on its interior side, creating an entrapment area and 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 |
| 6400.141(c)(11) | Individual #1's most recent physical examination, completed on 7/24/24, did not contain an assessment of their health maintenance needs, medication regimen, and the need for bloodwork at recommended intervals, as the form did not include any such field for entry. | 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. | 141 (c) (11) - The assessment of the individual¿s health maintenance needs, medication regimen and the need for blood work at recommended intervals.
January 14, 2025 ¿ The agency¿s nurse sent the current annual physical of the individual #1 to their primary care physician to update information pertinent to the individual personal wellness and need for blood work.
The PCP updated current physical to reflect required fields. |
01/14/2025
| Implemented |
| 6400.141(c)(14) | Individual #1's most recent physical examination, completed on 7/24/24, did not address medical information pertinent to diagnosis and treatment in case of an emergency. This field was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | 141 (c) (14): The physical exam shall include, medical information pertinent to diagnosis and treatment in case of an emergency.
January 14, 2025 ¿ The agency¿s nurse sent the current annual physical of the individual #1 to their primary care physician to update information pertinent to diagnosis and treatment in case of an emergency.
The primary care physician updated the annual physical with the required information. |
01/24/2025
| Implemented |
| 6400.216(a) | On 1/15/25, at 12:15 PM, the door to the staff office was equipped with a privacy lock that had a pinhole access point on its exterior side that can be disengaged with common objects, such as an ink pen cartridge, paper clip, or bobby pin. Inside the staff office was a computer that stored an electronic database of Individual #1's records. However, affixed to the desk next to the computer was a note providing access information that included the user id: "Washington" and password: "W@$hingt0nAv3." | 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 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 |
| 6400.32(h) | On 1/15/25, Individual #1's bedroom door was equipped with a key and keypad code combination locking system. This locking system is being operated using the keypad code option. However, a sticky note displaying the door lock code of "1111" was affixed just above the locking system on the outside of Individual #1's bedroom door in plain view for others to gain access. | An individual has the right to privacy of person and possessions. | 32 (h) An individual has the right to privacy of person and possessions.
January 15, 2025- The individual #1 private information that was located on a sticky note was immediately removed from the bedroom door and also in the staff's office.
Staff #1 immediately stored individual #1 private information in a locked file cabinet. |
01/24/2025
| Implemented |
| 6400.163(d) | On 1/15/25, at 12:38 PM, the home's accessible first aid kit was stocked with three packets of unlocked, over-the-counter medication with each packet containing two 325 mg tablets of Acetaminophen. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | 163 (d): Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.
January 15, 2025 ¿ The residential staff person #1 immediately disposed of (medication) located in the first aid kit, due to it not being in a locked container. |
01/24/2025
| Implemented |