| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.65 | The bathroom's skylight was inoperative; it could not be opened, leaving the bathroom without ventilation. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Based on the licensing review of November 9-10, 2022, the CLA Director, on 11/14/22, retrained the Site Supervisors responsible for the sites, as well as the Assistant Directors, about the importance of ensuring that skylights are operable for proper ventilation. |
12/02/2022
| Implemented |
| 6400.110(b) | The hallway smoke detector outside of the bedrooms was inoperative. During the inspection, the smoke detector was replaced and tested; the replacement is operative. | There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. | On the day of licensing 1 of 3 smoke detectors were not operational despite being operational the day before and a wire may have been inadvertently loosened during testing. Based on the licensing review of November 9-10, 2022, the CLA Director, on 11/14/22, retrained the Site Supervisors responsible for the sites, as well as the Assistant Directors, about the importance of ensuring that all smoke detectors are operable. |
11/10/2022
| Implemented |
| 6400.141(c)(6) | Individual 1's last physical indicated that a quantiferon tuberculosis screening was completed, however the results of the test were not listed. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Records indicate that the family was responsible for medical appointments during this time and did not ensure completion of this regulatory requirement in a timely manner. We will continue to work with family members to ensure completion of this important aspect of the individual¿s physical. Based on the licensing review of November 9-10, 2022, the CLA Director, on 11/14/22, retrained the Nurse Manager and Health Care Office Manager about the importance of ensuring that the individual¿s physical clearly indicates a negative Tuberculin test. The Nurse Manager is responsible to ensure all medical appointments/documentation are regulatory compliant. |
11/10/2022
| Implemented |
| 6400.32(r) | Individual 1's bedroom door cannot be locked; the door does not have a locking mechanism. | An individual has the right to lock the individual's bedroom door. | Based on the licensing review of November 9-10, 2022, the CLA Director, on 11/14/22, retrained the Site Supervisors responsible for the sites, as well as the Assistant Directors, about the importance of ensuring that individuals have the ability to lock their door. |
11/10/2022
| Implemented |
| 6400.46(a) | Staff Member 1 has not yet received fire safety training, though they have begun working with individuals. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | During the aftermath of COVID and ongoing high staff vacancies rates, we continue striving to ensure that staff receive key areas of health and safety training. Based on the licensing review of November 9-10, 2022, the CLA Director conferenced with the Director of Training responsible for providing and tracking this important training emphasizing this as health and safety item that must be completed per regulatory requirements. Additionally, the CLA Director, on 11/14/22, retrained the Site Supervisors responsible for the completion of the training, as well as the Assistant Directors about the importance of ensuring that new staff are trained in fire safety before working with individuals. |
11/10/2022
| Implemented |
| 6400.186 | Individual 1's ISP indicates poisonous materials are kept locked in the apartment as a precaution. Bottles of dish detergent were found on the kitchen sink and in an unlocked cabinet beneath the sink. | The home shall implement the individual plan, including revisions. | This citation was resolved immediately on 11/10/22, while licensors were still on site, the Site Supervisor stored the detergent in a locked cabinet. Based on the licensing review of November 9-10, 2022, the CLA Director, on 11/14/22, retrained the Site Supervisors responsible for the sites, as well as the Assistant Directors about the importance of keeping poisonous materials properly secured as per regulatory requirement and as directed by the ISP. The residential staff at this site were also given verbal feedback about the importance of complying with 6400 regulations on the day regarding ensuring that cleaning material are properly secured, (11-10-22). |
11/10/2022
| Implemented |