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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The basement of the home had a few piles of dirt, dust, debris, rusted construction nails, small construction items approximately the size of screws, cobwebs, a few dead bug carcasses, and occasional leaf in all rooms in the basement. Individual's items are stored in the basement area. | Clean and sanitary conditions shall be maintained in the home. | This regulation is important because it minimizes the risk of illness, infection, or injury and provides a dignified living environment.
At the time of the inspection, the basement area of the home had piles of dirt, dust, debris, cobwebs, dead bugs, leaves, and rusted construction items.
This occurred because the Program Supervisor and Program Specialist failed to ensure that all areas of the home were clean and sanitary. Although the basement of the home is not used for anything other than storage, it should still be clean and sanitary.
Immediately following the inspection, the basement was cleaned. See Attachment #17 for proof.
On 3/20/2023, Program Specialists were retrained on the expectation of ensuring unused areas in the home are still clean and sanitary per regulation. See Attachment #4 for proof of training.
The Program Specialists are completing an audit of all homes to ensure all areas of the home are clean and sanitary. This audit will be completed by March 31, 2023. In the event there are identified areas in the home that are in violation of regulation 64(a), the Program Specialist will develop a Plan of Correction that will be completed by April 6, 2023. |
03/29/2023
| Implemented |
| 6400.110(g) | According to the 8/11/22 fire drill record, a smoke detector was faulty during testing from the fire drill and maintenance was going to fix it. The facility has not provided documentation of notification for the repair needed within 24 hours of noticing the faulty detector, or documentation of repairs completed. | If a smoke detector or fire alarm is inoperative, notification for repair shall be made within 24 hours and repairs completed within 48 hours of the time the detector or alarm was found to be inoperative. | This regulation is important because malfunctioning smoke detectors will not protect individuals from injury or death in the event of a fire.
On 8/11/2022, there was a faulty smoke detector that prompted 911 to be called. Maintenance fixed the faulty smoke detector on 8/12/2023. However, there was no documentation to support that the smoke detector was repaired within 24 hours, aside from a text message between the Program Supervisor and Program Specialist.
This happened because the agency failed to ensure proper documentation was completed.
On 3/20/2023, Program Specialists were retrained on the expectations of ensuring proper documentation is obtained from the maintenance department regarding any repairs that occur. Attachment #4 is proof of training.
On 4/12/2023, Program Supervisors will be retrained on the expectations of ensuring proper documentation is obtained from the maintenance department regarding any repairs that occur. |
03/29/2023
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Nail polish was unlocked in the bathroom and in an individual's bedroom. An unlocked cabinet in the garage contained spray paint, Simple Green cleaner, bug spray and motor oil. The first aid kit was stored in the kitchen area and contained antiseptic and hydrogen peroxide. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Nail polish has been locked. The cabinet in the garage was removed and the contents were moved offsite by the Maintenance department.
See attachment B
The first aid kit was supposed to be stored in the locked closet in the staff area, however someone had failed to return it to this area at the time of the inspection. All staff in the home were trained on the need for any potential poisonous materials to be locked.
See attachment D
All Residential Supervisors and Program Specialist level staff were trained on the need to be more mindful of the need for potentially poisonous materials to be kept locked in homes where ALL individuals do not have adequate awareness.
See attachment A |
10/12/2016
| Implemented |
| 6400.67(a) | Individual #1's long dresser was missing a knob on the top right drawer. | Floors, walls, ceilings and other surfaces shall be in good repair. | Knob was replaced on the dresser.
See attachment C
All Residential Supervisors and Program Specialist level staff were trained on the need to be more mindful of furniture knobs. Program Specialists now look for this during their monthly site visits.
See attachment A |
10/12/2016
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | The baseboard heater in the bathroom to the left of the hallway is very rusted. | Floors, walls, ceilings and other surfaces shall be in good repair. | Heater was sanded and repainted. Due to the type of heat/heater it was best to sand/repaint than to replace.
See attachment F
Physical site inspections is part of the monthly site montiorings completed by Program Managers monthly.
All Residential Supervisors and Program Managers received additional training regarding this matter/regulation on August 13, 2014
See attachment A |
08/13/2014
| Implemented |
| 6400.80(b) | The back patio leading out from the basement of the home had a large area of peeling paint. The porch roof is falling apart and the fence along the back is falling apart and sharp areas of the fence are hanging from it. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The entire area that was sited was removed. This area was not used by individuals and was in need of too much repair. There is a patio off of the dining room that is used by individuals.
See attachment F
Physical site inspections is part of the monthly site mountings completed by Program Managers monthly.
All Residential Supervisors and Program Managers received additional training regarding this matter/regulation on August 13, 2014
See attachment A
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12/15/2014
| Implemented |
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