| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 20.34 | A room on the second floor of the residence was locked and inaccessible. | The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agentsof the Department to privately interview staff and clients. | The Associate Director will be reminded that authorized agents must be provided access to all areas of the home that are subjected to inspection. Keys and/or appropriate access procedures will be readily available to ensure that inspectors are not delayed or denied access to any area of the residence. The AD will also be remined that authorized agents must be provided the opportunity to privately interview individuals and staff without unnecessary interruptions or interference. The Program Director will review inspection procedures with all Associate Directors to reinforce expectations regarding announced and unannounced inspections. |
09/30/2026
| Implemented |
| 6400.64(a) | Two areas of the home require a thorough cleaning: behind the clothes dryer and the corner lazy Susan in the kitchen. | Clean and sanitary conditions shall be maintained in the home. | The area behind the clothes dryer was immediately cleaned thoroughly to remove accumulated dirt, dust, lint, and debris. The corner lazy Susan cabinet in the kitchen was thoroughly cleaned and sanitized, including the shelves, corners, and surrounding areas. The Associate Director will retrain staff on the expectations that all areas of the home, including less visible and difficult to reach areas, must be cleaned and maintained. These areas will be included into the homes daily cleaning check list to prevent a recurrence. |
07/13/2026
| Implemented |
| 6400.77(b) | The first aid kit did not contain a thermometer. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | The thermometer was obtained and placed in the first-aid kit immediately. The first aid kit will be inspected weekly to ensure all required supplies are present, current and readily available. Staff will be retrained to report any missing, expired, or depleted first aid supplies to the Associate Director or Program Director immediately. The first-aid supply check will be added to the Associate and Program Directors monthly checklist to ensure all supplies are available. |
09/30/2026
| Implemented |