| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | There was Lysol and Swiffer wet jet liquid solution in a dining room unlocked cabinet, despite at least one individual, individual #1 who cannot handle poisons safely. | Poisonous materials shall be kept locked or made inaccessible to individuals. | On 1/16/2023, the Program Specialist retrained all staff on the requirements of locking up poisonous materials if the ISP contains that residents cannot safely handle poisons as sited in Chapter 6400.62(a). |
01/16/2023
| Implemented |
| 6400.64(a) | There was a large accumulation of dust on the wall besides the phone in the dining room.
The kitchen microwave and oven need a deep cleaning, as the microwave has food stuck on the ceiling and the stove has a large grease buildup.
The kitchen cabinets interior and fronts need a thorough deep cleaning to clean stuck on food residue and crumbs.
The entire perimeter of this home's baseboards needs a good cleaning as they have a large accumulation of dust and debris on them.
The second-floor bathroom needs a thorough cleaning. | Clean and sanitary conditions shall be maintained in the home. | On 1/23/2023, the CEO scheduled a house deep cleaning provided by a third-party cleaning company. All current staff were retrained on house cleaning and sanitation (See attached exhibit B). New weekly cleaning log developed and utilized for all shift responsibilities (see attached exhibit C). |
01/23/2023
| Implemented |
| 6400.64(f) | There are trash bags and empty boxes, not inside of a trash receptacle outside the basement side exit. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | The CEO ordered new trash bins with attached lids for the outside on 1/3/2023. All staff were retrained on the policy of trash removal and disposal on closed receptacles to reduce risk of penetration of insects and rodents (exhibit B). A responsibility cleaning schedule was developed and implemented for all staff to utilized (see exhibit C). |
01/16/2023
| Implemented |
| 6400.66 | The living room ceiling light is not able to be turned on. This light is attached to a ceiling fan which can only be operated by a remote control which could not be located during the inspection. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| on 1/3/2023, CEO located the report for the ceiling light and fan. The holder for the remote was screwed to the wall to reduce risk of misplacement. The CEO turned the light on and off to ensure it was functioning. Staff were trained on where to keep the remote to ensure it does not get misplaced. |
01/03/2023
| Implemented |
| 6400.67(a) | The kitchen window has broken kitchen blinds that are taped together.
Individual #3-bedroom outlet cover closest to the bed is detached from the wall and wiggles when touched.
The second-floor bathroom medicine cabinet shelves are broken. | Floors, walls, ceilings and other surfaces shall be in good repair. | The CEO replaced the broken blinds in the kitchen. The outlet cover in individual #3 bedroom was secured and the second-floor bathroom medicine cabinet shelves were repaired by All in One Construction company. The staff were retrained on the timing of maintenance request submissions (see exhibit B). |
01/05/2023
| Implemented |
| 6400.67(b) | The hallway wall leading to from the first to the second floor has six deep, large holes where the old banister was that needs repair. | Floors, walls, ceilings and other surfaces shall be free of hazards. | On 1/5/2023 All In One Construction agency fixed the holes in the wall where the old banister was secured. The staff were retrained on the submission of maintenance requests to the house supervisor (see attached). |
01/05/2023
| Implemented |
| 6400.72(a) | The back basement security door is missing the bottom glass and the handle inside of the home is not securely affixed to the door. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | On 1/5/2023 All In One Construction agency removed the broken door and securely fixed the handle on the door. The staff were retrained on the submission of maintenance requests to the house supervisor (see exhibit B). |
01/05/2023
| Implemented |
| 6400.77(a) | There is no tape in the first aid kit. | A home shall have a first aid kit. | On 1/20/2023 the CEO replaced the tape within the first aid kits and reviewed all items to ensure they did not need to be replenished by utilizing the quarterly report (see exhibit A). |
01/20/2023
| Implemented |
| 6400.110(a) | The smoke detectors throughout the home were not operational at the time of inspection. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | On 12/22/2022, the CEO interconnected the smoke detectors and tested them to ensure they were operable. On 1/16/2023, the staff were retrained on the smoke detector requirements and expectations of fire drills. In addition, staff were retrained on the process of information the house supervisor should a smoke detector fail during a drill and the agency policy on communication timeframe (see Exhibit B) |
12/22/2022
| Implemented |
| 6400.110(e) | This three story home did not have smoke detectors that were interconnected with one another. | 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. | On 12/22/2022, the CEO interconnected the smoke detectors and tested them to ensure they were operable. On 1/16/2023, the staff were retrained on the smoke detector requirements and expectations of fire drills. In addition, staff were retrained on the agency's timeline of communication with the house supervisor should a smoke detector fail during a drill (See exhibit B) |
12/22/2022
| Implemented |
| 6400.112(e) | Asleep drill is not indicated on the form. | A fire drill shall be held during sleeping hours at least every 6 months. | The CEO developed a new fire drill form to include the date, time, meeting location and all members involved in the fire drill (See exhibit D). Staff were retrained on utilizing the new form and capturing all information (see attached training sing-in sheet). |
01/16/2023
| Implemented |
| 6400.112(h) | This is no meeting place designation indicated on the fire drill logs. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | The CEO developed a new fire drill form to include the date, time, meeting location and all members involved in the fire drill (See exhibit D). Staff were retrained on utilizing the new form and capturing all information (see attached training sing-in sheet). |
01/16/2023
| Implemented |
| 6400.181(e)(8) | The Assessment does not include individual #2 understanding in how to evacuate in a fire. | The assessment must include the following information: The individual's ability to evacuate in the event of a fire. | On 1/5/2023, the CEO retrained the Program Specialist and house supervisor on documenting each individual's knowledge of fire safety and evacuation ability (see exhibit E). A new annual assessment was completed with individual #2 and his team on 1/18/2023, and his ability to evacuate in the event of a fire was reviewed and documented. |
01/18/2023
| Implemented |
| 6400.181(e)(13)(iv) | The assessment Personal adjustment section was left blank for individual #1 | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | On 1/5/2023, the CEO retrained the Program Specialist and house supervisor on the completion of the annual assessment to ensure no sections are left blank (see exhibit E). An annual assessment was completed with individual #1 and his team on 2/28/2023 and the individuals progress over the last 365 and current level of personal adjustment was reviewed and documented in the assessment. |
01/05/2023
| Implemented |
| 6400.181(e)(14) | The Assessment does not include individual #2 ability to swim or temper water.in water safety.
The assessment section referencing the individual #1 knowledge of water safety and ability to swim did not explain how they can manage around bodies of water. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | On 1/5/2023, the CEO retrained the Program Specialist and house supervisor on capturing all information of the annual assessment, including but not limited to swimming and tempering with water, and the ability to swim (see exhibit E). On 1/18/2023 the annual assessment was updated for individual #2 and his team and documented the individuals ability to swim and/or temper with water. On 2/28/2023 individual #2 and his team completed his annual assessment and the program specialist documented his knowledge of water safety and ability to swim. |
01/05/2023
| Implemented |
| 6400.165(g) | Quarterly psychotropic review was not completed every three months for individual number 2 . Dates on review are 3/17/2022, 6/23/2022. Psychotropic review dated 9/16/2022 does not indicate the need to continue the medication. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | On 1/5/2023, the CEO retrained the house supervisor and program specialist on the required times line for the psychotropic review to occur (See exhibit E). A new calendar tracking system was implemented to ensure quarterly reviews are not missed. |
01/05/2023
| Implemented |