| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(d) | There was a case of Acadia water bottles housed in the garage with chemicals. The water was removed immediately after discovery. | Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces. | Our 6400.32(h) protocol has been updated and the following procedures have been instituted;
- The case of water was relocated to an alternative storage area within the home and away from all chemicals. Staff and program managers were trained on the new location of the water and on the need to ensure food items are completely separated from chemical storage areas. Proof of completion is in Attachment # 3. |
10/14/2022
| Implemented |
| 6400.72(b) | The right window in the living room was not able to stay open without being held open and there were no handles on the kitchen windows. the right window in individual 3's bedroom did not remain open went lifted. | Screens, windows and doors shall be in good repair. | Our 6400.67(a)protocol has been updated and the following procedures have been instituted;
A work order to fix the kitchen window was placed and the work was completed. Proof of completion is in Attachment # 5.
A work order to fix both the living room window and the right window in individual 3's bedroom was placed. According to the Facilities department, the target completion date will be 11/15/2022 due to the back orders on parts required to fix the windows. |
10/14/2022
| Implemented |
| 6400.73(a) | There was no railing on the stairs when entering the attic space | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | A work order to add railing to the stairs entering the attic space was placed. (Attachment #7). |
10/14/2022
| Implemented |
| 6400.81(k)(1) | Individual 2's bed was very low to the floor. Agency staff stated it was due to the individual being a falling risk, however, the safety risk was not notated in the individual plan or program assessment. | In bedrooms, each individual shall have the following: A bed of size appropriate to the needs of the individual. Cots and portable beds are not permitted. Bunkbeds are not permitted for individuals 18 years of age or older. | The health and safety rational for the bed modification has been updated in the individual's assessment. (See Attachment # 9 Updated assessment).
The health and Safety rational for the bed modification has been communicated with the Supports Coordinator to ensure this is updated in the ISP.
Script for rationale has been obtained from the doctor for health and safety. See attachment #10 |
10/14/2022
| Implemented |