| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.81(k)(6) | No mirror was located in the room of Individual #2 at time of inspection | In bedrooms, each individual shall have the following: A mirror. | Regulation 6400. 81K6:
Importance of Regulation
o This regulation is critical for ensuring that individuals right to maintain as it relates to Everyday Lives.
Regulation Violated
o No mirror was located in the room of Individual #2 at time of inspection.
Fix of Violation
¿ Staff placed the mirror back in the individual¿s room on 3/29/21
Responsible Person
o Summer Kollie is responsible to prevent future violations.
o Acute anticipated the resolution of this violation by 3/29/21
o Violation was resolved on 3/29/21
o Based on analysis of other individuals, similar violation occurred at one another home and was corrected (Individual #3). |
03/29/2021
| Implemented |
| 6400.82(e) | There was no non-slip mat present in the shower/tub at the time of the inspection | Bathtubs and showers shall have a nonslip surface or mat. | Regulation 6400. 82E:
Importance of Regulation
o This regulation is critical for maintaining the safety of the individual.
Regulation Violated
o Bathtubs and showers shall have a nonslip surface or mat.
Fix of Violation.
¿ A shower mat was bought and placed it in the individual¿s bathroom
Responsible Person
o Summer Kollie is responsible to prevent future violations.
o Acute anticipated the resolution of this violation by 4/15/21
o Violation was resolved on 4/17/21
o Based on analysis of other individuals, there are no similar violations |
04/17/2021
| Implemented |
| 6400.82(f) | No hand soap present in the bathroom at the time of the inspection | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Regulation 6400. 82F:
Importance of Regulation
o This regulation is critical for maintaining the safety of the individual.
Regulation Violated
o No hand soap present in the bathroom at the time of the inspection.
o Staff was trained on the appropriate soap to buy and to follow proper procedure for making house purchases. Staff bought the appropriate soap and placed it in the individual¿s bathroom.
Fix of Violation.
o Staff bought safe soap which is appropriate for use and placed it in the bathroom
Responsible Person
o Summer Kollie is responsible to prevent future violations.
o Acute anticipated the resolution of this violation by 4/15/21
o Violation was resolved on 4/17/21
o Based on analysis of other individuals, there are no similar violations |
04/17/2021
| Implemented |
| 6400.111(f) | The Fire extinguisher located in the kitchen was last inspected in Feb 2020. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | 19-9 Valley Road Physical Site
Regulation 6400. 111A:
Importance of Regulation
o This regulation is critical for maintaining the safety of the individual.
Regulation Violated
o The Fire extinguisher located in the kitchen was last inspected in Feb 2020.
Fix of Violation
¿ The fire extinguisher in question was transported for maintenance and placed in the kitchen.
Responsible Person
o Douglas Jones is responsible to prevent future violations.
o Acute anticipated the resolution of this violation by 4/15/21
o Violation was resolved on 3/30/21
o Based on analysis of other individuals, there are no similar violations |
03/30/2021
| Implemented |
| 6400.141(c)(10) | Individual #2's Physical form had communicable diseases left blank. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | Regulation 6400. 141C.10:
Importance of Regulation
o This regulation is critical for maintaining good health of the individual.
Regulation Violated
o Individual #2's Physical form had communicable diseases left blank.
Fix of Violation.
o The box on the individual¿s physical form which states `individual is free of all communicable diseases¿ was not checked by the physician. At the individual¿s most recent PCP visit on 5/20/21 the Dr. correctly filled the form out
Responsible Person
o Summer Kollie is responsible to prevent future violations.
o Acute anticipated the resolution of this violation by 5/20/21
o Violation was resolved on 5/20/21
o Based on analysis of other individuals, there are no similar violations |
05/20/2021
| Implemented |
| 6400.181(e)(14) | Water safety isn't indicated on the assessment for Individual#2 | 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. | Regulation 6400. 181E.14:
Importance of Regulation
o This regulation is critical for maintaining the safety of the individual.
Regulation Violated
o Water safety isn't indicated on the assessment for Individual#2
Fix of Violation
o Program specialist review individual monthly and quarterly progress report and update the annual report to reflect the individual water safety and progress.
Responsible Person
o Summer Kollie is responsible to prevent future violations.
o Acute anticipated the resolution of this violation by 5/3/21.
o Violation was resolved on 5/3/21.
o Based on analysis of other individuals, there are no similar violations |
05/03/2021
| Implemented |