| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | Surfaces shall be in good repair. A lower cabinet door in the kitchen located to the left of the kitchen stove was missing a drawer pull or knob. | Floors, walls, ceilings and other surfaces shall be in good repair. | Maintenance was contacted and cited items were addressed. Maintenance will do a full sweep of all homes to ensure that all cabinets and cupboards are in good repair. |
12/31/2023
| Implemented |
| 6400.112(a) | An unannounced fire drill shall be held at least once per month. There is no documentation that a fire drill was held during the months of August 2023, July 2023, June 2023, May 2023, March 2023, February 2023, December 2022, November 2022 or September 2022. In the twelve months from September 2022 to August 2023, there is documentation that only three unannounced fire drills were completed. | An unannounced fire drill shall be held at least once a month. | Program Manager and DSP's working at all locations will be re-trained in the above mentioned regulation. Fire drill was completed. Fire drills will be conducted on a monthly basis. |
12/31/2023
| Implemented |
| 6400.216(a) | Individual's records shall be kept locked when unattended. In the basement of the home, there is a file storage room where individual and employee records are stored. At the time of the inspection, the door to the storage room was open wide, allowing access to the files. Additionally, the walls of the storage room did not reach to the floor and there were open areas at the bottom that an adult-size person could crawl through in order to access the files. The steps to the basement are open, without a door, and accessible to the residents, staff or anyone inside the home. | An individual's records shall be kept locked when unattended.
| Maintenance was contacted and walls were rebuilt. Door was locked. CEO met with administrative staff and maintenance to explain regulations. Door was open from a flooding issue and walls were removed due to water damage, however, files should have been relocated or other measures taken to ensure security. |
12/31/2023
| Implemented |