| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | There is no property record for Individual #1. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | QLHS had individual #1 property record located in the individual's big book. QLHS will have the team lead check Individual #1 property sheet on a monthly bases to ensure that it is updated when needed according to ODP regulation. QLHS supervisor or program director will conduct monthly checks to ensure that we a incompliance. |
09/23/2020
| Implemented |
| 6400.64(e) | There were no lids on the garbage cans in the basement. One of the garbage cans was filled with debris. | Trash receptacles over 18 inches high shall have lids. | QLHS will corrected the violation on 10/14/20 the trash can with no lid and the one that was field with debris will be removed by the Program Director.
QLHS designated person will conduct monthly check to ensure we are incompliance with ODP regulations. |
10/14/2020
| Implemented |
| 6400.67(a) | The left door on the closet in the 2nd bedroom was off-track. | Floors, walls, ceilings and other surfaces shall be in good repair. | QLHS has corrected the violation the top of the shower has been scraped painted. QLHS is hiring a new maintenance person to handle the repairs in the homes. To ensure that the problem does not accrue again QLHS will complete the Monthly Checks so we remain incompliance with ODP regulations. |
08/29/2020
| Implemented |
| 6400.68(b) | The water temperature in the bathroom was an in the basement was 146 degrees, exceeding the regulated temperature. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | QLHS has correct the water temperature violation Apgar oil company came in to put water temperature regulator on the temperature is currently at 118.
QLHS team lead will also so a bi- weekly checks to ensure that the water temperature meet ODP regulations. QLHS designated person will conduct monthly checks to ensure that we are incompliant with ODP regulations. |
10/29/2020
| Implemented |
| 6400.82(f) | There was no hand soap, paper towels and toilet paper in Individual #1's bathroom. | 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. | QLHS will schedule a meeting with individual #1 ISP to reflect why she is not able to have these items in her bathroom. QLHS will call the county human rights team to address these restrictions due to her throwing things in the toilet. |
11/14/2020
| Implemented |
| 6400.111(f) | The fire extinguisher in the basement was not inspected. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | QLHS correct the violation for the fire extinguishers not being inspected on 09/23/2020 a picture was sent to the inspector the same day. QLHS will utilize the assessment form to ensure that we are incompliant with ODP regulation. |
09/23/2020
| Implemented |
| 6400.112(a) | Staff were instructed to conduct a fire drill on the day of this inspection to determine the ability staff and the individual to evacuate. Before pulling the alarm, staff put shoes on Individual #1 and brought her out to the front door. This was not an unannounced fire drill. | An unannounced fire drill shall be held at least once a month. | QLHS will retrain the staff on conduction the proper unannounced fire drill according to ODP regulation . QLHS designed person will conduct unannounced fire drill on the a monthly bases to ensure that we are incompliant with ODP regulation. |
10/14/2020
| Implemented |
| 6400.112(d) | The fire drill held on 8/24/2020 had an evacuation time of 5 minutes. No problems were noted for this fire drill. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | QLHS designated person will retrain staff on the proper evacuation time according to ODP regulations.
To ensure that QLHS are incompliance with ODP the designated person will conduct the monthly fire drill and the supervisor will check the fire drills monthly. |
11/14/2020
| Implemented |
| 6400.141(c)(6) | Individual #1 was admitted on 8/24/2020. Her TB test was dated 4/13/2019, which is more than 1 year prior to admission. She had another TB test 9/9/2020, which was approximately 2 weeks after her admission. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | QLHS designated person and supervisor will check the individuals records to ensure the fills are update according to ODP regulation. A check sheet will be created to help monitor the items that are required |
11/14/2020
| Implemented |
| 6400.141(c)(7) | Individual #1 was admitted on 8/24/2020. She has no record of a gynecological exam being performed. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | QLHS has taken individual #1 to see a gynecologist on 9/25/20 but the doctor was not able to exam her. The doctor rescheduled another exam for 10/9/20 and prescribed medication to taken before her appointment. Due to the virus QLHS was not able to schedule a earlier appointment. QLHS supervisor or designated person will assess the team lead with scheduling all required appointment. |
09/25/2020
| Implemented |
| 6400.151(a) | Staff #3 had physical completed on 1/10/2018 and did not have another one completed until 2/13/20. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | QLHS will hire an HR person to review the staff chart to ensure that we are incompliant with ODP regulation. QLHS designated person will do monthly check to ensure staff is in compliant with ODP regulations.
((HR person Kerry has been hired 11/17/20 CH)) |
11/30/2020
| Implemented |
| 6400.151(c)(2) | Staff #3 had a TB test completed on 1/20/18 and did not have another one completed until 2/14/2020. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | QLHS will hire an HR person to review the staff chart to ensure that we are incompliant with ODP regulation. QLHS designated person will do monthly check to ensure staff is in compliant with ODP regulations.
((HR person Kerry has been hired 11/17/20 CH)) |
11/30/2020
| Implemented |
| 6400.46(b) | Staff had annual fire safety on 2/8/2019 and not again until 4/5/2020. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | QLHS designated person will delegate the office manager to check the staff records to ensure that we are incompliance with ODP regulation until we hire another HR person to fulfill the role.
QLHS program director and program specialist will also check fills on a monthly bases |
11/30/2020
| Implemented |