| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(b) | At the time of the inspection on 11/15/23, there was a slightly larger than a golfball size of lint in the dryer. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Lint screen was cleaned on 11/15/2023 and staff were trained by the Program Manager on the regulatory requirement concerning lint removal. Training occurred on 11/28/2023. See supporting documentation. |
12/18/2023
| Implemented |
| 6400.81(k)(1) | At the time of the inspection on 11/15/23, there was no bed in individual #2's bedroom. | In bedrooms, each individual shall have the following: A bed of size appropriate to the needs of the individual. Cots and portable beds are not permitted. Bunkbeds are not permitted for individuals 18 years of age or older. | Individual #2 does not wish to have or sleep in a bed. It has been added to the ISP that they do not wish to have a bed and prefers to sleep in their recliner. Changes were made to the ISP and staff were trained on the updated ISP on 11/28/2023. See supporting documentation. |
12/18/2023
| Implemented |
| 6400.81(k)(2) | At the time of the inspection on 11/15/23, there was no mattress or foundation in individual #2's bedroom. | In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. | Individual #2 does not wish to have or sleep in a bed. It has been added to the ISP that they do not wish to have a bed and prefers to sleep in their recliner. Changes were made to the ISP and staff were trained by the Program Manager on the updated ISP on 11/28/2023. See supporting documentation. |
12/18/2023
| Implemented |
| 6400.81(k)(6) | At the time of the inspection on 11/15/23, there was no mirror in individual #1's bedroom. | In bedrooms, each individual shall have the following: A mirror. | A mirror was purchased and placed in individual #1's bedroom on 11/15/2023. Staff were trained by the Program Manager on the requirement for a mirror in all individuals bedrooms on 11/28/2023. See supporting documentation. |
12/18/2023
| Implemented |
| 6400.32(d) | At the time of the inspection, individual #2 did not have a bed available to them at their residence. Staff indicated individual #2 prefers to sleep in the chair and that this is outlined in the ISP. The individual's ISP does not indicate this as the individual's preference, however. | An individual shall be treated with dignity and respect. | Individual #2 does not wish to have or sleep in a bed. It has been added to the ISP that they do not wish to have a bed and prefers to sleep in a recliner. Changes were made to the ISP and staff were trained by the program manager on the updated ISP on 11/28/2023. See supporting documentation. |
12/18/2023
| Implemented |