| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(f) | On 6/7/23, at 12:10 PM, there were two uncovered trash receptacles in the front of the home containing miscellaneous trash. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | Four additional garbage cans with secure lids were purchased by the facility supervisor on 6//2023. The cans are large enough and plentiful enough to encompass all of the waste for the home for the week where each lid can be securely closed. If there is an excess of waste in one week, the extra bags of waste that do not fit in the supplied cans will be taken to the main administrative office to be disposed of in the dumpster that the agency supplies. The facility supervisor will monitor the trash weekly to make sure that it is all secure, if it is not he will assign a staff person, verbally and via the staff note system to take the extra trash to the administrative office for placement in the agency dumpster. |
06/20/2023
| Implemented |
| 6400.76(a) | On 6/7/23, at 11:52 AM, the three drawers on the right side of the dresser in Individual #2's bedroom are not correctly assembled and fall out when opened. This could cause a possible injury hazard to the individual. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The facility director will purchase a new dresser for Individual #2. The existing director will be disposed of when the new dresser is delivered. This will be completed by 7/7/2023. |
07/07/2023
| Implemented |
| 6400.81(k)(3) | On 6/7/2023, at 11:50 AM, Individual #2 did not have linens on their mattress or a pillowcase on their pillow. | In bedrooms, each individual shall have the following: Bedding, including pillow, linens and blankets appropriate for the season. | 1. A zip up mattress cover will be purchased for individual #2¿s bed. This will be completed by the facility supervisor by 6/23/2023 and put on the bed immediately upon purchase.
2. A zip up pillowcase will be purchased for individual #2¿s pillow. This will be completed by the facility supervisor by 6/23/2023 and put on the pillow immediately upon purchase.
3. Bed sheet fasteners will be purchased to use with individual #2¿s fitted bed sheet to keep it securely in place. This will be completed by the facility supervisor by 6/23/2023 and put on the bed sheet immediately upon purchase. |
07/07/2023
| Implemented |
| 6400.110(f) | On 6/7/23, at 12:05 PM, Individual #1's bed was not equipped with a bed shaker. Individual #1's assessment, completed 6/27/2022, states the individual needs additional equipment for fire safety including, "strobe lights within the home, additional horns to sound alarm and bed shaker to alert him when the alarm sounds and when sleeping." There were no fire alarms equipped with strobe lights in the bathrooms, kitchen, or other common areas of the home that would allow the Individual #1 to be notified in the event of a fire. The only fire alarm equipped with a strobe light was located in the Individual #1's bedroom. | If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. | 1. The bed shaker for individual #1¿s bed was located and put back on their bed (they had removed it and hid it from the staff). Completed by facility staff on 6/8/2023.
2. Recommendations from an alarm expert were obtained for placement of the bed shaker to make it less assessable. The bed shaker was repositioned on the bed on 6/20/2023.
3. The agency will have additional strobe lights installed in the home, to include the kitchen, the bathroom, the basement and the attached garage area. Contact with the alarm expert completed on 6/13/23 by Program Director. Parts are being ordered and installation will occur by 7/14/2023. |
07/07/2023
| Implemented |