| 2380.86 | On 6/18/2025 at 1:44PM, three portable space heaters were inside the furnace room that is also utilized as a storage closet. | Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including offices. | 06/18/2025 space heaters in storage closet were immediately removed from the building. |
07/31/2025
| Implemented |
| 2380.111(c)(10) | Individual #1's physical examination, completed 3/20/2025, does not address medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | 06/30/2025 Individual #1's physical was returned to the doctor's office and the "Medical Information Pertinent to Diagnosis" was signed off by CRNP who completed the physical. The physical was faxed back to Lifesteps and was placed in Individual's file. |
07/31/2025
| Implemented |
| 2380.182(c) | Individual #1's assessment, completed 10/10/2024, states that the individual is independent with poisonous materials. Individual #1's service plan, most recently updated, 1/8/2025, reads, "[Individual #1] needs supervision when using cleaning products to ensure proper use, storage, and personal health and safety." Individual #1's assessment, completed 10/10/2024, states that the individual is able to independently evacuate the building in the event of a fire. Individual #1's service plan, most recently updated, 1/8/2025, reads, "[Individual #1] recognizes a fire alarm but would require verbal prompts to safely evacuate a building and meet in a designated area; [Individual #1's] mom believes [Individual #1] would get scared from the alarms and might not evacuate without support." Individual #2's assessment, completed 2/26/2025, states that Individual #2 needs verbal prompting to recognize and move away from heat sources. Individual #2's service plan, last updated 6/12/2025, reads, "[Individual #2] is able to recognize common hazardous materials, heat sources, and other dangers both in [Individual #2's] home and in the community." | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | 07/01/2025 Individual #1's ISP was updated to reflect the assessment completed 10/10/2024 at Lifesteps ACOR Program.
06/30/2025 Individual # 2's ISP was updated to reflect the Assessment completed 02/26/2025 at Lifesteps ACOR Program. |
07/31/2025
| Implemented |