Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.62(a) | Individual 1's ISP indicates cleaning materials are kept locked in the house. Poisonous materials were found in an unlocked cabinet beneath the hallway bathroom's sink, including Febreze spray and several bottles of hand sanitizer. | Poisonous materials shall be kept locked or made inaccessible to individuals. | All poisons were locked on 8/30/2022 by associate director (Attachment #49). |
08/30/2022
| Implemented |
6400.62(c) | A viscous material consistent with hand soap was found in a decorative soap dispenser in Individual 3's bathroom. | Poisonous materials shall be stored in their original, labeled containers. | All poisons were locked on 8/30/2022 by associate director. Decorative soap dispenser was replaced by hand soap in its original container on 8/30/2022 (Attachment #50). |
08/30/2022
| Implemented |
6400.64(a) | Individual 3's toilet was found in an unsanitary condition, filled with yellow liquid and black material consistent with human waste and grime all around the toilet bowl. The bathroom had a strong urine smell. | Clean and sanitary conditions shall be maintained in the home. | Individual 3's bathroom was cleaned by residential coordinator on 8/31/2022 (Attachment #51). |
08/31/2022
| Implemented |
6400.64(f) | Trash bags and boxes were found on the ground next to garbage cans in the backyard. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | All trash bags were relocated to the appropriate trashcans on 8/31/2022 by residential coordinator (Attachment #52). |
08/31/2022
| Implemented |
6400.110(c) | There was no smoke detector located in a common area within 15 feet of Individuals 1 and 2's bedrooms. After the inspection, the agency provided a photo showing a smoke detector had been installed in the hallway. | The smoke detectors specified in subsections (a) and (b) shall be located in common areas or hallways. | A new smoke detector was placed in the common area by Delta maintenance on 8/31/2022 (Attachment #53). |
08/31/2022
| Implemented |
6400.111(c) | The kitchen did not have a fire extinguisher. The nearest extinguisher was in the dining room. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | Fire extinguisher was hung on the wall in the kitchen by Delta maintenance on 9/6/2022 (Attachment #54). |
09/06/2022
| Implemented |
6400.144 | Pharmaceutical services are not being fully rendered. An over-the-counter bottle of generic acetaminophen was found in an unlocked kitchen cabinet. It was not labeled so it could not be determined if the medication belonged to or was being administered to any individual in the house. A staff member later indicated the medication was theirs. Individual 3's fluocinonide sol. 0.05% medication was expired, with an expiration date of January 2022. Individual 3's medication kit was also missing two PRNs called for on their MAR: banophen cap. 25mg, and benzoyl per gel 5%. The medications were not located in the home and as such were not available for the individual to use if needed. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Bottle of generic acetaminophen was removed from the home by the residential coordinator on 8/29/2022. Individual 3¿s fluocinonide sol. 0.05% was re-orded by associate director and delivered to the home on 8/30/2022 (Attachment #55). Individual 3¿s two PRN medications were located in the home on 8/30/2022 and moved to the medication boxes for proper storage (Attachment #55). |
08/30/2022
| Implemented |
6400.171 | An open package of smoked turkey was found in a storage freezer in the washroom. | Food shall be protected from contamination while being stored, prepared, transported and served.
| Open package of turkey was removed by associate director on 8/29/2022 (Attachment #56). |
08/30/2022
| Implemented |
6400.163(f) | Individual 2's prescription arginine medication was found stored in the refrigerator alongside food, without a separate locked container. | Prescription medications stored in a refrigerator shall be kept in an area or container that is locked. | A medication lock box for the fridge was purchased and medications were safely stored in the locked box in the fridge by residential coordinator on 8/30/2022 (Attachment #57). |
08/30/2022
| Implemented |