| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | Soap was found in a decorative container on the bathroom sink. | Poisonous materials shall be stored in their original, labeled containers. | As of August 2, 2023, Lifetime Skills, under the supervision of the Executive Director who oversees the House Manager, has taken steps to ensure that all residential homes are provided with body wash, and this body wash will be maintained in its original labeled containers. Additionally, Lifetime Skills will continue to ensure that all potentially hazardous materials are securely stored, prioritizing the safety of the individuals. |
08/02/2023
| Implemented |
| 6400.63(a) | Hot water in the kitchen sink was measured at 149 degrees; in the bathroom sink at 143 degrees. | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | On August 5, 2023, the Executive Director of Lifetime Skills, in collaboration with the maintenance department, made necessary adjustments to the water temperature in both the bathtub and kitchen areas to ensure compliance with regulatory standards, setting it at a permissible level of 120 degrees. Furthermore, the Director, site manager, and maintenance personnel will conduct comprehensive checks on the water temperature at all residential sites to ensure full compliance with ODP regulations. |
08/05/2023
| Implemented |
| 6400.67(b) | A thick build-up of lint was found in the dryer lint trap, posing a fire hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Upon the discovery of lint in the dryer, the staff promptly removed it. |
07/18/2023
| Implemented |
| 6400.68(b) | Hot water was measured in the bathroom tub at 144 degrees | Hot water temperatures in bathtubs and showers may not exceed 120°F. | On August 5, 2023, the Executive Director of Lifetime Skills, in collaboration with the maintenance department, made necessary adjustments to the water temperature in both the bathtub and kitchen areas to ensure compliance with regulatory standards, setting it at a permissible level of 120 degrees. Furthermore, the Director, site manager, and maintenance personnel will conduct comprehensive checks on the water temperature at all residential sites to ensure full compliance with ODP regulations. |
08/05/2023
| Implemented |
| 6400.141(a) | There was no physical in the record for individual 2. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | An individual is required to undergo a physical examination within 12 months prior to their admission and annually thereafter.
Regrettably, in the case of Individual 2, he was in the midst of his transition for admission to Lifetime Skills, and we were still in the process of obtaining his previous records from the agency he came from when he was released to Lifetime Skills, leading to his classification as an emergency intake. |
10/28/2023
| Implemented |
| 6400.142(a) | There was no dental appointment in the record for individual 2 | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | On August 3, 2023, the program specialist received the training to avoid this violation. The PS updated dental records for all individuals, scheduling appointments for each individual to complete their annual dental examinations and ensuring that Individual #2 receives an annual dental examination. |
08/03/2023
| Implemented |
| 6400.165(b) | Individual 2's ISP indicated that individual 2 takes several medications for depression and mood disorder. Staff indicated individual 2 arrived without medication and has not been taking medication. Below is the list of daily medications indicated on individual 2 ISP.
1. Valproic acid syrup
2. Clonidine.01 mg
3. Guanfacine er 4mg
4. Apripolozole 30 mg
5. Sertraline 50 mg | A prescription order shall be kept current. | Individual 2 did not have all his current medications available in the home during the inspection due to his ongoing transition period. Furthermore, it was unclear if a CLA was appropriate for this individual. The individual is no longer with Lifetime skills. Lifetime Skills was not able to fully procure all Individual 2's medications, resulting in a violation of Chapter 6400.165(b). The responsibility for obtaining all necessary documents upon an individual's admission into Lifetime Skills CLA, and ensuring ongoing compliance, rests with both the Lifetime Skills Program Specialist and the intake specialist. |
08/02/2023
| Implemented |
| 6400.213(1)(i) | there was no Personal information included for individual 2 on the face sheet.
The name, sex, admission date, birthdate and Social Security number.
The race, height, weight, color of hair, color of eyes and identifying marks | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Individual 2 violated Chapter 6400.213(1)(i) due to the absence of personal information on the face sheet. The client denied participation for doing his face sheet. However, Lifetime Skills program specialist has successfully updated the face sheets for all individuals, ensuring that they now include the required personal information, which includes: (i) The name, sex, admission date, birthdate, and Social Security number. For Example, see attachment # 12 |
08/10/2023
| Implemented |