| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self-assessment was not completed within 3 to 6 months prior to the expiration date of the agency's certificate of compliance. The self-assessment was dated 3/17/2023 and the expiration date for the certificate of compliance is 5/07/2023. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| QLHS designated person and Supervisor are the responsible parties to ensure the self- assessment will be filed out and submitted to ODP in a timely manner. |
07/24/2023
| Implemented |
| 6400.81(k)(6) | The bedroom used by Individual #8 did not have a mirror. | In bedrooms, each individual shall have the following: A mirror. | QLHS will meet with Individuals #8 SC to discuss updating his ISP to reflect that having a mirror in his room is a health and safety concern at this time.. |
07/31/2023
| Implemented |
| 6400.82(f) | The bathroom located in the bedroom hallway did not have individual clean paper towels or cloth towels. | 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 has corrected this violation. Paper towels was placed in the bathroom during inspection. |
07/24/2023
| Implemented |
| 6400.110(e) | The home has 3 levels and the smoke detectors installed in the home were not functioning in an interconnected manner at the time of the inspection. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | QLHS designated person ordered new smoke detectors. QLHS maintenance staff put them up and made sure the smoke detectors are interconnected with each other and functioning properly. |
07/31/2023
| Implemented |
| 6400.112(c) | The fire drill records for fire drills that occurred on 1/30/2023, 12/30/2022 and 8/20/2022 did not record the evacuation time. The fire drill record for the fire drills that occurred on 11/30/2022 and 9/30/2022 did not record the exit route used. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | QLHS staff will be retrained on how to fill out all fire drill records and it entirety. |
07/24/2023
| Implemented |
| 6400.112(e) | During the 12-month period from May 2022 through April 2023, only one fire drill was held during sleeping hours; that drill occurred on 3/27/2023 at 1:00 AM. Sleeping hours are considered to be 11 PM to 7 AM unless the home can demonstrate that another time period more accurately reflects sleeping hours. Staff indicated that a fire drill conducted on 11/30/2022 at 2:00 PM was a "sleep drill," but that time does not fall in the time range considered to be sleeping hours. | A fire drill shall be held during sleeping hours at least every 6 months. | QLHS will retrain staff on how to fill out the fire drill form and how often an awake and asleep drill to done.
Also, staff will be trained on sleep hours and awake. |
07/31/2023
| Implemented |
| 6400.151(a) | Staff #2 had a late annual physical examination with TB testing by Mantoux method. Staff #2 had a physical exam and Mantoux on 9/20/2020, then not again until 5/09/2023. Staff #2 is a staff person who does come into direct contact with the individuals that the Agency supports and is required to have annual physical examinations and TB testing every two years. | 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 staff # 2 picked up the physical form from the doctors office. The administration will continue to review staff required documents to ensure that we are in compliance with ODP regulations. |
07/31/2023
| Implemented |
| 6400.32(r)(1) | The bedroom door lock for Individual #8 was a "coin-lock" style locking device which does not provide the level of privacy and security as intended by the regulation. | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | QLHS has placed a code lock on individual #8 bedroom door to ensure the individuals privacy. |
07/03/2023
| Implemented |