| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Clean and sanitary conditions are not being maintained in the home. The tops of the kitchen cabinets were covered in grease and dust.
A picture collage on the left wall facing the front window in the living room was covered in a layer of dust. | Clean and sanitary conditions shall be maintained in the home. | The cabinets and picture frame were cleaned that day. A staff meeting is being scheduled to review the chore checklist and the expectation of completion of chores with all staff members. The Program Director will review Regulation 6400.64(a) with the Program Coordinator and the house staff during the staff meeting to ensure all employees are clear on this expectation |
04/01/2022
| Implemented |
| 6400.67(a) | The wall behind the bedroom door in the first floor bedroom was not in good repair, there was a hole in the wall. | Floors, walls, ceilings and other surfaces shall be in good repair. | Work order was submitted that day and hold has since been repaired. A staff meeting is being scheduled to address the process for identifying and reporting maintenance concerns. The Program Director will review Regulation 6400.67(a) with the Program Coordinator and the house staff during the staff meeting to ensure all employees are clear on this expectation. |
04/01/2022
| Implemented |
| 6400.46(d) | Staff #4 was trained in First Aid/CPR on 4/12/19 and did not receive training again until 6/15/21. The renewal training was late. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Employee was out on leave and no longer works for the agency. |
04/15/2022
| Implemented |