| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.46(f) | Staff #1, received fire safety training on 1/15/21, which was more than a year from the previous training in fire safety on 11/13/19. | 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. | Woods has revised their training plans to create a structured design related to training course completion dates. |
05/31/2021
| Implemented |
| 6400.76(a) | Individual#1's dresser was missing the left drawer handle, second from the top | Furniture and equipment shall be nonhazardous, clean and sturdy. | Handles replaced on 2/8/2021. |
05/31/2021
| Implemented |
| 6400.80(a) | Fire escape/exit on the second floor was not clean of snow and staff was unable to open the door to exit. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | Shovels supplied to Residential Managers to confirm all exits are cleared during the snow season, was supplied on 2/9/2021. |
05/31/2021
| Implemented |
| 6400.101 | Fire escape/exit on the second floor was not clean of snow and staff was unable to open the door to exit. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Shovels supplied to Residential Managers to confirm all exits are cleared during the snow season, was supplied on 2/9/2021. |
05/31/2021
| Implemented |
| 6400.15(b) | Items 32 v and 34s door locks not assessed. Item 112e on the assessment not completed for fire drills | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | Removed as per MJ at ODP. |
03/19/2021
| Implemented |
| 6400.165(d) | The acetaminophen was expired at time of inspection. | A prescription medication shall be used only by the individual for whom the prescription was prescribed. | All nurses and medication trained/certified staff will document that they have read and understand the Woods' Medication Administration Manual. |
05/31/2021
| Implemented |
| 6400.166(a)(13) | Fluocinonide was not initialed as being administered on 2/6/21 at 8PM for individual#1. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | All nurses and medication trained/certified staff will document that they have read and understand the Woods' Medication Administration Manual. |
05/31/2021
| Implemented |