| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | Poisonous materials were not kept in their original containers. In a laundry room cabinet, a handful of loose Tide Pods were found in a small plastic container rather than the detergent's original packaging. | Poisonous materials shall be stored in their original, labeled containers. | This was corrected immediately during the on-site inspection |
06/25/2021
| Implemented |
| 6400.64(a) | At inspection, in the basement kitchen, material consistent with dirt was found in both sink basins, around its sides and drains. Around the perimeter of the kitchen basement floor was a layer of white or grey powder consistent with dust, and a back corner wall near the basement bathroom was covered in a spray of light brown droplets that covered both walls of the corner. The basement kitchen oven was observed to have material consistent with dust or dirt across its range and hood. The basement dishwasher had black and grey specks throughout its interior consistent with mildew, dirt, or dust. The washing machine was observed to have a thick yellow/brown build up on and around the top of its center spoke. Food material was also observed in the bottom of the primary kitchen's dishwasher, and material consistent with grease or food waste was found accumulated around the interior of the primary kitchen's microwave. The ceiling light in the primary bathroom was observed to have a large amount of material consistent with dust accumulated on the interior of its casing, and the ceiling vent near it also had accumulated dust or dirt. | Clean and sanitary conditions shall be maintained in the home. | Although the basement is not used, the kitchen sink was cleaned. See attachment 6 |
06/25/2021
| Implemented |
| 6400.64(e) | A trash can in the kitchen area was observed to not have an operational lid at time of inspection. | Trash receptacles over 18 inches high shall have lids. | A new trash can was purchased soon after the inspection. The trash can has a lid as required. See attachment 7 |
06/04/2021
| Implemented |
| 6400.67(a) | In the basement kitchen, the cabinet above the oven on the left is missing a handle, and cabinets under that same kitchen's sink are missing knobs. The wall behind the bathroom basement door is damaged, the damage matching up with the bathroom doorknob's height and size. The basement closet door nearest the stairs is also missing a handle. | Floors, walls, ceilings and other surfaces shall be in good repair. | Although the basement is not used by the individuals, it is an old apartment that JEVS does not use, we replaced the knobs and handles on the cabinets. See attachment 8. |
06/25/2021
| Implemented |
| 6400.80(a) | Not all pathways around the house were found to be free from obstructions at time of inspection. The pathway that faces Beechwood Rd. and connects the front door to the back porch area was obscured by a large bush, and going around the bush required leaving the path and walking on the grass. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | The bushes have been trimmed and all pathways are clear. See attachment 5 |
06/10/2021
| Implemented |
| 6400.144 | Individual#1 did not have all medications listed on the MAR. The Albuterol Sulfate HFA inhaler PRN medication listed on the MAR was not in the house at time of inspection. New documentation from the pharmacy showing the medication's discontinuation as of 6/2/21 was provided by the agency during inspection. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| This medication was discontinued as stated above by the inspector. The medication was removed from the home on 6/2/21. |
06/02/2021
| Implemented |
| 6400.181(d) | The Program specialist did not sign and date Individual#1's assessment. | The program specialist shall sign and date the assessment. | The program specialist has signed the assessment. She was instructed to ensure that all assessments and other required documents are signed in a timely manner going forward |
06/10/2021
| Implemented |
| 6400.32(d) | The Office of Developmental Programs requires that staff who provide direct services wear a mask that covers the nose and mouth during the entirety of service provision. During the inspection on 6/3/21, staff member#1 was observed to not be following proper mask protocols while preparing and serving lunch for the household's residents. At times during the inspection, the mask was half off, exposing the nose, and at other times was resting below the chin, fully exposing the nose and mouth. Failure to wear masks is undignified and disrespectful in that it creates a risk of transmitting the COVID-19 virus from staff to individuals. | An individual shall be treated with dignity and respect. | The staff person in question was disciplined for this incident. All staff have been reminded by the Director of Operations in an email, that ODP still requires that masks are to be worn. |
06/04/2021
| Implemented |
| 6400.163(d) | The house residents' medications were observed to be kept in an unlocked cabinet in the kitchen area. Both the cabinet and the individual plastic containers in which the medications were stored were found to have no locks. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | The medication is now stored in a locked cabinet . See attachment 4 |
06/07/2021
| Implemented |