| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | A golf ball size amount of lint was found in the dryer trap during the physical site walk through on 03/10/23. | Clean and sanitary conditions shall be maintained in the home. | Lint is a fire hazard. Statistics show that dryers are the cause of more than 20,000 household fires every year, totaling millions of dollars in damage. (Source: The Spruce - https://www.thespruce.com/dryer-vent-lint-fire-hazard-).
The regulation is important because fire outbreaks may occur if the staff continue to leave lint in the dryer. Diligently removing lint from dyers will prevent incidents of fire outbreaks in the home. This will ensure safety for both the individuals and staff.
For immediate correction and compliance, the following were done:
Immediate training was provided for all staff in the home on ¿The Importance of Removing Dryer Lint¿ (Training Source: The Spruce - https://www.thespruce.com/dryer-vent-lint-fire-hazard-).
Two reminders (Appendix #1) were placed on top of the dryer to provide visual assistance for staff to be able to remember to remove the lint from the dryer:
o A big one (letter size) placed on the wall behind the machine.
o A smaller strip is placed on top of each machine.
These will serve as reminders for each staff member when they finish laundry. |
06/01/2023
| Implemented |
| 6400.64(d) | A trash bag containing trash was sitting on top of the trash can at the time of the walk through on 03/10/23. | Trash in the bathroom, dining and kitchen areas shall be kept in cleanable receptacles that prevent the penetration of insects and rodents. | This is a violation because the Regulation states that, Trash in the bathroom, dining and kitchen areas shall be kept in cleanable receptacles that prevent the penetration of insects and rodents.
This regulation is important because placing trash in receptacles prevents the spread of diseases. The risk of insect and rodent infestation is also minimized. When trash is placed in the appropriate receptacles, it minimizes the risk of individual illness, injury, rodent and insect infestation, and provides dignified living conditions for individuals.
This violation occurred because the staff on duty did not complete her task before she went to answer the doorbell. The staff member stated that she had removed trash from the bedroom and bathroom in a bid to complete her cleaning in the home on that morning. She was on her way to place the trash in the big trash receptacle outside the home when she heard the doorbell. She quickly placed it on the kitchen trash can and went on to answer the door. She had not had a chance to remove it before the inspector saw it. According to her, she was still going to remove it, but she was trying to attend to the inspector.
The immediate correction is that all staff were advised to always complete all their tasks appropriately, rather than get distracted. The other option is to get permission from the inspector that a task needed to be completed quickly. |
06/01/2023
| Implemented |
| 6400.66 | There is no light in the hallway outside of Individual #1's bedroom. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The regulation states that, Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
The benefit of this is that it ensures a rapid evacuation in the event of an emergency, and minimizes the risk of falls or other injuries due to inadequate illumination.¿
At the time of inspection, there was no light in the hallway outside of Individual #1s bedroom.
This is a violation. The violation occurred because the Facilities Staff wrongly assumed that the other light in the hallway would serve for outside of the individuals room as well.
For immediate correction and compliance, the light was installed on the day after the inspection (Appendix #2).
The Compliance Staff and Program Specialist will ensure adherence to all regulations pertaining to the physical site, going forward. |
06/01/2023
| Implemented |
| 6400.71 | Two telephones in the living room and one in the staff office do not have emergency phone numbers. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| The regulation states that, Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
This violation occurred because the numbers were typed up on letter-sized paper and placed under each phone cradle. The individual in the home had destroyed them during incidents of property destruction. This proves that having the numbers on paper is not the smartest idea.
This regulation is important because emergency situations are unpredictable. If emergency assistance is required, staff, individuals, and visitors must be able to reach assistance immediately. Having these numbers posted on each telephone facilitates a quick response from the appropriate agency in the event of an emergency.
For immediate correction, the numbers have been typed on sticky labels and attached to each phone (handset) in the home (sample in the picture in Appendix #3). |
06/01/2023
| Implemented |
| 6400.214(b) | Individual # 1's current physical examination, Dental examination, Current Assessment and Current ISP were not at the home at the time of the walk through on 03/10/23. Staff Person # 2reported that the books were brought to the office on 03/09/23. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| Individual #1s records were not in the home because the home was being investigated and the folders had been removed to the office in order to be able to send the necessary documentation requested to the investigating body.
These folders had been going back and forth since the investigations started on 3/6. There had been five investigations, and different agencies had been involved. These included, the Case Management Unit, State Licensing, the Advocacy Alliance, Adult Protective Services, and the Office of Developmental Programs. With the intensity and depth of each investigation, the folders have had to be removed back and forth. Documentations had been moved around in their folders in order to maintain the privacy and integrity of the documents. |
06/01/2023
| Implemented |
| 6400.166(b) | Staff person # 2 reported during the physical site walk through at 9:00 am that she did not have the Medication Administration available for review and that she did not record the Medication administration for the morning medications immediately after giving the medications. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Staff person #2 did not have the Medication Administration Record available for review because she did not have access to the record. She had not yet completed her Medication Administration Training, and as such could not administer medication as of 3/10/2023. Staff Person #2 completed her Med Admin Training on 3/16/2023 (Certificate attached as Addendum #4). Another staff person administered medication, as is the practice until new staff complete their Medication Administration Training. The attached Medication Administration Record shows the administrator for 3/10/2023 (Addendum #5). |
06/01/2023
| Implemented |