| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | At time of inspection there was Aveeno brand lotion located in the bedroom individual #4 that contained a poison control warning on the back. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The Aveeno Lotion was removed and placed in the locked medication area on 7/15/21. |
07/15/2021
| Implemented |
| 6400.81(k)(6) | There was no present mirror in individual #3's room at time of inspection. | In bedrooms, each individual shall have the following: A mirror. | Mirror added to the bedroom on 7/17/21. |
07/17/2021
| Implemented |
| 6400.101 | At time of inspection the garage door was obstructed by items such as a chair and a rolled-up carpet. Additionally the staff reported that the garage door could not be opened from the inside.
** Provider showed photos showing that the obstructions were removed during the inspection and the garage
door was opened prior to exit. **
At time of inspection there was a keypad lock on the door that lead into the garage which did not allow for easy evacuation in the event of an emergency. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| All items were removed immediately on 7/15/21. Staff at the home were given the keypad lock code on 7/15/21. |
07/15/2021
| Implemented |
| 6400.104 | Fire Letter dated 7/6/21 stated that there were 2 individuals living in the home however there were 3 individuals 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.
| All Fire Letters have been updated for the cited home effective March 2022, as well as for all other homes. |
03/10/2022
| Implemented |
| 6400.110(e) | The home has three floors including the basement and the attic however they were not interconnected smoke alarms at the time of inspection. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | Installed new fire alarm system- completed 2/11/22; due to Covid precautions, this could not be done sooner. |
02/01/2022
| Implemented |
| 6400.112(a) | There were no fire drills completed in the months of May and June of 2021 | An unannounced fire drill shall be held at least once a month. | The Fire Drill for this location was run on July 21. There was no drill run in May or June and no way to recreate this for the cited months. Starting in July 2021, Unnanounced Fire drills are held monthly and tracked on the fire drill check list by location, by the Director of Residential. |
07/21/2021
| Implemented |
| 6400.142(e) | The most recent dental appointment for Individual #2 was completed on 11/3/20. The appointment as well as the ISP say that she will have a 3 month follow up which has not yet been completed.
** There is one scheduled in August 6th** | Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed. | The 8/6/21 appointment was cancelled due to Covid, and occurred on 9/13/21 instead. The individual then had follow up appointments on 11/2/21 and 11/9/21, 12/9/21, as well as 1/25/22 as follow up from 12/9/21 cavity work. |
09/13/2021
| Implemented |
| 6400.142(f) | There was no current dental plan at time of inspection for individual #2. | 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. | The Dental Plan was completed 7/20/21. |
07/20/2021
| Implemented |
| 6400.144 | Individual #2's PRN Acetaminophen 500 MG and PRN Triple Antibiotic Ointment both could not be located on site at time of 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.
| Both of these medications were reordered in July 2021, and have been reordered since as well. |
07/16/2021
| Implemented |