| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | There was a strong smell of urine in the home at the time of the inspection, primarily in the hallway leading to the bedrooms, as well as in each of the three individual bedrooms. | Clean and sanitary conditions shall be maintained in the home. | This location serves multiple individuals who are incontinent. To address this concern the home has been repainted and cleaned. Staff assigned to this location will be retrained on the facility chore list and process to ensure continued compliance. |
09/01/2021
| Implemented |
| 6400.32(r)(3) | Each bedroom door was equipped at the time of inspection with a keypad door lock with a key option, Licensing representative discussed the individual's ability to utilize the key pad with staff and was informed that the individuals are unable to use the keypads at the present time, but that staff are working with the individuals to help them learn to use keypad. Licensing representative discussed the door lock with individual #1 who was present in the home at the time of the inspection. Individual #1 stated that she is unable to use the keypad and would feel more comfortable with a key to lock and unlock her bedroom door, but a key was not provided to the Individual. | Assistive technology shall be provided as needed to allow the individual to lock and unlock the door without assistance. | All agency locks have both keypad and key lock accessibility. Our policy does indicate accommodations must be made to assist individuals in having the ability to open their doors. At the time the door was equip with a lock the individual was able to use the keypad and did not request a key, however keys are available in the home. The agency will review our policy with the individual and the ability for her to have a key if she does continue to request a key one will be made available and if she needs assistance staff will provide training and assistance with the key. |
09/01/2021
| Implemented |
| 6400.213(1)(i) | Next of kin was not included in the record for Individual #1. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate, Social Security number; and (v) next of kin. | The EHR face sheet has been updated to include Next of Kin. The individuals plan will be updated to ensure compliance |
09/01/2021
| Implemented |