| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | The upper right dresser drawer in Individual 1's bedroom, where the television rested, was missing a knob | Floors, walls, ceilings and other surfaces shall be in good repair. | This citation was resolved on 11/10/20 when the missing knob was replaced on the dresser with a new knob. Based on the licensing review of November 9-10, 2020, the CLA Director sent an email to all Residential Site Supervisors responsible for the sites, as well as the Assistant Directors, re-emphasizing that all furniture must be keep in clean, sturdy and good repair as per regulatory requirement. The Residential Site Supervisor will ensure regulatory compliance during their weekly site visits via Zoom or in person. This will be further emphasized in the monthly CLA Supervisory Solutions meeting. |
11/10/2020
| Implemented |
| 6400.82(e) | There was no nonslip mat in the bathroom shower at the time of physical site review. | Bathtubs and showers shall have a nonslip surface or mat. | This citation was resolved on 11/10/20 when a new bathmat was purchased and placed in the tub. Based on the licensing review of November 9-10, 2020, the CLA Director sent an email to all Residential Site Supervisors responsible for the sites, as well as the Assistant Directors, re-emphasizing that all showers and tubs must have a nonslip bathmat to prevent falls. The Residential Site Supervisor will ensure regulatory compliance during their weekly site visits via Zoom or in person. This will be further emphasized in the monthly CLA Supervisory Solutions meeting. |
11/10/2020
| Implemented |
| 6400.104 | Notification to local fire department does not include exact location of bedrooms of the individuals needing assistance. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| This citation was resolved on 11/12/20, when the letter and accompanying information about the bedrooms of consumers¿ that need assistance was re-sent to the Fire Department. Based on the licensing review of November 9-10, 2020, the CLA Director re-sent the notification to the Fire Department with accompanying information regarding the location of consumers¿ bedrooms that need assistance. The CLA Director has set an Outlook reminder for the fire department letter to include identifying bedrooms of those that need assistance. |
11/12/2020
| Implemented |
| 6400.142(a) | Individual 2's dental exam was not completed annually. The most recent dental exam provided was dated on 8/27/19. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | This citation was resolved on 11/23/20, when the individual¿s dental exam was completed within the regulatory timeframe. Based on the licensing review of November 9-10, 2020, the CLA Director sent an email to ODP on 1/25/21 with an attached letter indicating that the dental office was closed due to COVID and therefore, individual 2¿s dental exam was late. Per regulations when state restrictions are not in place, The Residential Site Supervisor will ensure regulatory compliance in consultation with the healthcare team. This will be further emphasized in the monthly CLA Supervisory Solutions meeting. |
11/23/2020
| Implemented |
| 6400.32(i) | The closet in Individual 1's bedroom was locked and inaccessible to individual. There was no mention of the locked closet in the individual support plan and it was unknown if the individual had a key to the closet.
The assessment dated 4/1/20 stated the individual rearranges the room often and enters closet to remove items. There was no mention of an agreement or permission to lock the closet in the assessment or a safety precaution. | An individual has the right of access to and security of the individual's possessions. | This citation was resolved on 11/12/20, when the old door lock was replaced with a new unlocked doorknob on the closet. Based on the licensing review of November 9-10, 2020, the CLA Director sent an email to Residential Site Supervisors responsible for the sites, as well as the Assistant Directors, re-emphasizing that consumers¿ closets must not be locked, but rather accessible to the consumer. The Residential Site Supervisor will ensure regulatory compliance during their weekly site visits via Zoom or in person. This will be further emphasized in the monthly CLA Supervisory Solutions meeting. |
11/12/2020
| Implemented |