| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.43(b)(1) | Reliance's Covid policy- (pg.3), requires staff to wear masks at all times-none of the staff at the homes inspected were wearing masks, (pg.5) of Reliance's Covid policy requires visitors to be screened by asking questions, taking temperatures, and recording temperatures-none of this occurred at any of the sites inspected this date. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | A memo was sent out to all staff to adhere to the company policy regarding wearing of masks while working at the homes |
09/27/2022
| Implemented |
| 6400.64(a) | Spiderweb in hallway ceiling- needs to be cleaned. | Clean and sanitary conditions shall be maintained in the home. | The ceiling fan was cleaned by the staff shortly after the inspection. The cleaning checklist in the home has been updated to included the cleaning of the fans at least once a month |
11/01/2022
| Implemented |
| 6400.65 | The ventilation in the bathroom is not operable- needs to be repaired. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| The House Supervisor filed a maintenance request with the leasing office for this to be rectified |
11/02/2022
| Implemented |
| 6400.66 | Light in the kitchen not working- needs bulb. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The house Supervisor purchased new bulbs and installed them in the home. Extra bulbs were also stored in the closet as back up. Incidentally, that bulb burnt on the day of inspection |
09/28/2022
| Implemented |
| 6400.76(a) | TV in the living room has a shattered screen and needs to be replaced. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The TV was shattered a day before inspection by the individual living in the home. A new TV was purchased shortly after and installed in the home |
09/28/2022
| Implemented |
| 6400.112(e) | A sleep drill has not been held since December 2021 | A fire drill shall be held during sleeping hours at least every 6 months. | See documentation attached that shows a fire drill was done on October 13, 2022 |
10/12/2022
| Implemented |
| 6400.141(a) | Individual 3 did not have a physical exam within 12 months prior to admission (11/16/2021), examination form is dated 02/02/2022. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The intake form for all new individuals has been updated to include admission date and annual physical deadline which must be within 12 months prior to admission and annually thereafter |
10/05/2022
| Implemented |
| 6400.142(e) | The Dental Examination form dated 05/24/2022 indicated that individual 3 to return to the dentist for fillings on 06/15/2022 at 9:00am. There is no verification provided that individual was taken to follow-up appointment. | Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed. | The paperwork was requested from the dental office and it was faxed over to us |
10/05/2022
| Implemented |
| 6400.151(c)(3) | The physical for staff 1 doesn't indicate if she is free of communicable diseases. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | The medical paperwork was sent back to the PCP to attest that the individual is free of communicable diseases |
10/04/2022
| Implemented |
| 6400.181(a) | An Assessment for Ind. 3 was not provided a year prior or 60 days after admission date of her arrival which was 11/16/2021. The assessment provided is dated 05/10/2022. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | The intake form for all new individuals has been updated to include initial assessment date deadline of 60days after arrival at the program |
10/05/2022
| Implemented |
| 6400.181(e)(6) | Individual 3's ability to avoid poisons was not addressed on the assessment dated 05/10/2022. | The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | The report was updated to reflect the following: Stephine is very aware and conscious of her environment. She does have a sense of awareness with regards to poisonous materials. However, staff is expected to be on hand to supervise her at all times and ensure poisonous materials are locked away safely after use to avoid any unsafe exposure |
09/28/2022
| Implemented |
| 6400.52(a)(1) | Training record for staff2 reports that she completed only 16hrs of the 24 required hours annually | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | The staff was made to complete the remaining 8 hours of training to remain compliant |
10/05/2022
| Implemented |
| 6400.213(1)(i) | Individual 3's record did not record the hair color, eye color or identifying marks, religious affiliation, and primary language. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | The individual's face sheet was updated immediately after the inspection to capture all of the pertinent information that was missing |
09/28/2022
| Implemented |