| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.65 | The windows in the dining room, living rooms, and both bathrooms cannot be opened. (No ventilation) | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Program Manager called contractor on 5/3/22 to notify of the need to repair the windows in the dining room, living rooms, and both bathroom as they cannot be opened. The Program Manager scheduled the earliest available appointment for the repair which will occur on 5/20/2022. See attachment #28, 29, 30. |
05/09/2022
| Implemented |
| 6400.46(b) | For staff #1 there is no indication that an annual fire safety training was completed by a fire safety expert within the last year. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Staff #1 attended fire safety training on 3/30/2021. Attendance sheet from 2021 training for staff was misfiled and located on 5/9/22 after licensing inspection. see attachment #26 |
05/09/2022
| Implemented |
| 6400.46(d) | There is no documentation of completed First Aid /CPR certificate for staff #1 | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Staff #1 attended CPR/First Aid training on 3/10/21. CPR card was misfiled for staff 1 was and located after licensing inspection on 5/9/22. See attachment #27 |
05/09/2022
| Implemented |
| 6400.52(c)(3) | There is no documentation that staff #1 completed individual rights training in the most recent completed training year. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Staff completed training on 3/30/21. Record misfiled in another staff's file. Record found on 5/9/22. see attachment #31. |
05/10/2022
| Implemented |