| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Carpets throughout the home are stained, worn, and need to be cleaned or replaced. | Clean and sanitary conditions shall be maintained in the home. | Program Director sent email to OPS listing area on non compliance. Carpets were replaced throughout the house. (Attachment # 19) |
12/22/2022
| Implemented |
| 6400.64(b) | · Cobwebs were found throughout the basement.
· Spider webs in dining room windows need to be cleaned. | There may not be evidence of infestation of insects or rodents in the home. | Program Director contacted an outside agency to clean the cobwebs throughout the basement and directed residential support staff to clean the spiderwebs in the dining room. (Attachment #20) |
01/16/2023
| Implemented |
| 6400.64(e) | There were three trash cans outside that were over 18 inches high that did not have lids on them at the time of inspection. | Trash receptacles over 18 inches high shall have lids. | Program Director directed residential support staff to purchase 3 new trashcans over 18 inches with lids on them and dispose of the old ones. (Attachment# 21) |
12/02/2022
| Implemented |
| 6400.64(f) | There were three trash cans outside overflowing with bags that did not have lids on them at inspection. Trash receptacles over 18 inches high shall have lids. Trash outside the home must be kept in closed receptacles to avoid the penetration of insects and rodents. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | Program Director directed residential support staff to ensure all bagged up and taken to the local dump site. (Attachment# 21) |
12/01/2022
| Implemented |
| 6400.67(a) | The 2nd landing of the basement steps is not sturdy and need to be repaired or replaced. | Floors, walls, ceilings and other surfaces shall be in good repair. | Program Director contacted an outside agency to repair the landing of the basement steps. Work was completed on 12/7/2022 and landing is now sturdy and in good repair. (Attachment #22) |
12/07/2022
| Implemented |
| 6400.72(a) | · The window in the 4th bedroom was not screened and
· No screen found in 3rd floor bathroom window.
· No screen found in 3rd floor bedroom used as office space | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Program Director sent email to OPS listing areas of non compliance. Screen was purchased and replaced in window. (Attachment # 23) : Program Director sent email to OPS listing areas of non compliance. Screen was purchased and replaced in window. (Attachment # 24): Program Director sent email to OPS listing areas of non compliance. Screen was purchased and replaced in window. (Attachment # 25) |
12/28/2022
| Implemented |
| 6400.72(b) | · The window in the 4th bedroom is cracked, needs to be screened and replaced.
· Door in kitchen where meds are housed is damaged and needs to be replaced.
· Left window in kitchen will not remain open on its own.
· Screen in kitchen window has a large hole and needs to be replaced. | Screens, windows and doors shall be in good repair. | Program Director sent email to OPS listing areas of non compliance. Screen was purchased and replaced in window. A request was made for broken window in bedroom and repair was made. (Attachment # 26)Program Director sent email to OPS listing areas of non compliance. A request was made and a new door was installed in the kitchen where to meds are stored. (Attachment# 27): Program Director sent an email to OPS listing areas of non compliance. Window was fixed and will now stay open. Screen in kitchen was purchased and replaced. (Attachment# 28 ) |
12/22/2022
| Implemented |
| 6400.81(k)(5) | There was no closet or wardrobe in individual's #1 bedroom. | In bedrooms, each individual shall have the following: Closet or wardrobe space with clothing racks and shelves accessible to the individual. | Program Director asked Program Manager to purchase a wardrobe for individuals room. However, due to backorder a wardrobe was moved was that not being used from one site to another. Once the new wardrobe arrives, the borrowed one will be returned.
The new wardrobe will be placed in individual¿s #1 bedroom when completed. Current Wardrobe attachment #29 placed in individual #1 bedroom. |
12/15/2022
| Implemented |
| 6400.82(f) | No toilet paper, cloth towel, or soap found in 2nd floor bathroom at inspection-paper towels and soap replaced during inspection. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Program Manager immediately directed staff to put toilet paper, paper towels and soap in the bathroom. Paper towels and soap were corrected during inspection. Liquid hand soaped was immediately placed in bathroom after inspection. Attachment# 30 |
12/02/2022
| Implemented |
| 6400.151(a) | Staff number 1 Physical exams dated 5/21/2019 and 7/7/2021 almost 2 months late. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | This specific physical was due during the pandemic when doctors were still not seeing patients as needed. This is the reason is why it was late. Staff was unable to schedule until the day she went. |
12/08/2022
| Implemented |