Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.62(a) | Poisonous materials shall be kept locked or made inaccessible to individuals. According to Individual #1's Individual Support Plan (ISP) poisonous substances are kept locked away or out of reach as a safety precaution. At the time of inspection, the right-hand kitchen sink cabinet was unlocked. Poisons are stored in this kitchen sink cabinet and the following poisons were located in the unlocked cabinet: a spray Clorox bathroom disinfecting cleaner spray bottle, Lysol disinfecting spray can, Lysol Power toilet bowel cleaner, a container of Lysol disinfecting wipes, and a 100 FL oz of Original Pin Sol Multi-surface cleaner. The labels on all of these items states to contact Poison Control Center. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Provider ensured that all poisons in the home were locked and inaccessible to the individual. Program staff were retrained on regulation 62a and individual #1's ISP guidelines regarding the storage or poisonous material. |
08/17/2023
| Implemented |
6400.64(a) | Clean and sanitary conditions shall be maintained in the home. The bathtub/shower floor located in the bathtub/shower on the left in the main bathroom had 4 substantial areas of rust on it. | Clean and sanitary conditions shall be maintained in the home. | Provider thoroughly cleaned shower area, removing areas of rust from the shower surface. Program Directors have checked all areas to ensure clean and sanitary conditions. |
08/21/2023
| Implemented |
6400.67(a) | Floors, walls, ceilings, and other surfaces shall be in good repair. The plastic hot water cap indicator was missing from the bathroom sink knob in Individual #1's bathroom. | Floors, walls, ceilings and other surfaces shall be in good repair. | The hot water cap was replaced on faucet immediately indicating which knob is for hot water. All other knobs were checked to ensure compliance. |
08/25/2023
| Implemented |
6400.68(c) | A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources' certified laboratory stating that the water is safe for drinking purposes at least every 3 months. A coliform test was completed on 2/16/23 and then not again until 6/6/23. This exceeds the requirement. | A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources¿ certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept. | Provider's water testing laboratory went out of business with little notice. The provider established accounts with a new water testing laboratory and testing was done as quickly as possible but exceeded the quarterly requirement, resulting in a late water test. |
08/23/2023
| Implemented |
6400.151(c)(3) | A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. Staff #1's physical examination dated 12/15/22 did not include that the staff person is free of communicable diseases. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | Director of Human Resources, obtained a physical examination including a signed statement, confirming that staff #1 is free from communicable disease. |
08/23/2023
| Implemented |