| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Clean and sanitary conditions are not maintained in the heating vent in the kitchen area of the home. The heating vent in the ceiling of the kitchen had a layer of dust. | Clean and sanitary conditions shall be maintained in the home. | The kitchen vent was cleaned within 48 hours of the licensing date. |
10/26/2023
| Implemented |
| 6400.104 | Notification to the fire department is not kept current. The most recent fire department notification dated 6/23/23 indicated that there are 5 individuals residing in the home. Currently, four individuals reside in the home. | 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.
| A letter (notification) will be sent to the Fire Company no later than 10/27/2023. |
10/26/2023
| Implemented |
| 6400.112(b) | Fire drills held on 6/16/23, 5/25/23, 4/18/23 12/22/22, and 9/28/22 were not held during normal staffing conditions. Normal staffing condition are a 2:4 ratio. There were three staff in the home assisting with fire drills on the listed dates. | Fire drills shall be held during normal staffing conditions and not when additional staff persons are present. | A successful fire drill was conducted on 10/3/2023 in which the staffing ratio was maintained. |
10/26/2023
| Implemented |
| 6400.112(d) | Individuals were not able to evacuate the home within the extended evacuation time of 3 minutes 15 seconds on 4/14/23. The evacuation took 3 minutes and 45 seconds. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | Our current fire drill log is being updated to include a statement about the amount of time permitted at each program of 2 1/2 min. or approved extended evacuation time. This will serve as a reminder of the regulated time upon completion of the form, and immediate action which may need to be taken. |
10/26/2023
| Implemented |
| 6400.112(f) | Fire drills are not held during sleeping hours at least every 6 months. There was a sleep fire frill conducted on 4/14/23 that was an unsuccessful drill and a successful sleep drill conducted on 4/30/23. There was not a sleep drill conducted prior to 4/14/23. | Alternate exit routes shall be used during fire drills. | A successful sleep drill was conducted on 10/3/2023. The staffing ratio was met (2:4). A sleep drill will be conducted in April 2024 as identified on the Fire Drill Log & Systems Check form. |
10/26/2023
| Implemented |
| 6400.142(f) | Individual #1 does not have a dental hygiene plan | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | Individual #1 will have a follow-up appointment scheduled immediately. Prospectus Berco's Dental form will be utilized and completed in its entirety to include the hygiene plan. |
10/26/2023
| Implemented |
| 6400.181(a) | Individual #1's annual assessment was completed late. Individual #1's annual assessment was completed 2/9/22 and not again until 6/8/23. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | The supervisor/associate director will ensure that the next assessment is completed no later than 6/7/2024. Checklists and oversight will be utilized to ensure timely completion. |
10/26/2023
| Implemented |
| 6400.181(e)(12) | Individual #1's assessment does not include Recommendations for specific areas of training, programming and services. Individual #1's assessment included an area for recommendations; however the area indicated the individual's current level and progress, not recommendations. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | An updated assessment will be completed by the program supervisor/Associate Director no later than 10/27/2023 which will include the training, programming, and services information required by regulation. |
10/26/2023
| Implemented |
| 6400.165(a) | Prescription medications are not prescribed in writing by an authorized prescriber. There were 5 packets or aspirin, 5 packets of non-aspirin and 3 packets of antacid located in the first aid kit that were not prescribed to any individual in the home. | A prescription medication shall be prescribed in writing by an authorized prescriber. | The non-aspirin and antacid packets were removed from the first aid kit and disposed of by end of licensing review. |
10/26/2023
| Implemented |