| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Basement storage items, including sealed and unsealed diapers, were strewn around the basement floor. | Clean and sanitary conditions shall be maintained in the home. | Program director immediately directed staff on site to begin cleaning the basement and disposing of items as needed. Email follow up to program manager followed Attachment # 25. Basement was completely cleaned and swept Attachment # 26. To prevent future occurrence: Community Home Review sheet was updated to include ensuring that basement of home (if applicable) is clean and free of hazards. Attachment # 27 |
12/03/2021
| Implemented |
| 6400.67(b) | There was chipping paint along the length of the interior dining room window panes. These areas were in need of stripping and repainting. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Program director sent email to OPS, reporting issue of non-compliance Attachment # 28. Window frames were scraped and painted Attachments # 29. To monitor compliance: Community Home Review sheet was updated to include ensuring that windows freely open and are equipped with screens and all materials in the home are in good repair Attachment # 30. |
12/13/2021
| Implemented |
| 6400.72(b) | The dining room windows are not operational; they were unable to be opened during inspection. There is a hole in the glass in a dining room window on the exterior glass pane of the window. | Screens, windows and doors shall be in good repair. | Program director sent email to OPS, listing the areas of non-compliance Attachments # 29 & 31. Screens were purchased and replaced in both side windows Attachment # 32. Glass in center stationary part of window was purchased and replaced Attachment # 33. To monitor compliance: Community Home Review sheet was updated to include ensuring that windows freely open and are equipped with screens and all materials in the home are in good repair Attachment # 34. |
12/13/2021
| Implemented |
| 6400.76(a) | The basement sink basin was full of cloudy, standing water accumulating from a slow-leaking faucet. | Furniture and equipment shall be nonhazardous, clean and sturdy. | : Program director immediately send email to OPS, reporting the clogged sink Attachment # 35. Sink was unclogged during inspection Attachment # 36. Follow up email was sent to OPS, requesting that plumber address the issue at the home Attachment # 37. Plumber addressed issue and supplied and installed new 3¿ PVC piping from front crawlspace through basement with necessary clean out fittings and connections to front bathroom, small fixtures, kitchen sink, washing machine and laundry tub Attachment # 38. To prevent future occurrence: Community Home Review sheet was updated to include ensuring that basement of home (if applicable) is clean and free of hazards. Attachment # 27. |
01/03/2022
| Implemented |
| 6400.80(b) | The last four wooden boards on front ramp were not secured on the left side of the boards and there was standing water underneath the boards at the time of inspection. There was a broken lamppost top lying under a tree in the backyard of the home. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | Program director sent email to OPS, listing areas of non-compliance Attachment # 39. OPS took up the deck boards on the ramp and filled in hollow section of the bottom of the ramp with concrete so it can¿t bounce and collect water Attachments # 40. Broken lamppost lying under a tree outside was disposed of Attachment # 41. To prevent future occurrences: Community Home Review sheet was updated to include ensuring outside of home is free of debris and hazards Attachment # 42. |
12/14/2021
| Implemented |
| 6400.165(g) | Individual 1 was seen on 02/09/2021 for a psychotropic medication review and was not seen again until 06/09/2021, which is 1 month more than the allotted regulatory time. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Late psychiatric medication review could not be fixed, as appointment had already occurred, and the timeframe of completion was already out of compliance. IDD compliance instituted a tracking sheet to monitor current and upcoming psychiatric medication review appointments, to ensure that the next appointment complies with the regulation Attachment # 43. Memo was sent to program managers, reminding them of licensing regulation and reminding them that in the absence of a psychiatrist reviewing prescribed medications, a PCP could do so Attachment # 44. To prevent future occurrences: IDD compliance will track and monitor that psychiatric medication reviews are scheduled and completed at least every 90 days Attachment # 43. |
12/10/2021
| Implemented |