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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Poisonous material was not kept locked and was accessible to the individuals. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Direct care staff and the program coordinator were retrained on the importance of ensuring the individuals health and safety especially when it comes to ensuring that Poisonous materials shall be kept locked or made inaccessible to individuals. At the time of the inspection staff had mistakenly forgotten to lock the cabinet and once notified that this cabinet was not locked, the error was rectified onsite at the time of the inspection. The program coordinator was also retrained on the home biweekly checklist and the importance of utilizing it to ensure health and safety of our Indvidual's within the homes including poison safety. Staff were also retrained on poison safety level of the individuals within theier assigned home . |
06/09/2023
| Implemented |
| 6400.66 | The light in the bathroom shower area was not operating properly. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Direct care staff and the program coordinator were retrained on the importance of ensuring the individuals health and safety are high priority and 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 light fixture in the bathroom was taken down and the light bulb checked and replaced, and it is now in working order as of 5.23.23. The program coordinator was also retrained on the home biweekly checklist and the importance of utilizing it to ensure health and safety of our Indvidual's within the homes. |
06/09/2023
| Implemented |
| 6400.76(a) | The towel rack in bathroom #1 was damaged. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Direct care staff and the program coordinator were retrained on the importance of ensuring that the Furniture and equipment shall be nonhazardous, clean and sturdy. The towel bar was purchased and repaired/replaced by 5/23/23 in the bathroom. The program coordinator was also retrained on the home biweekly checklist and the importance of utilizing it to ensure health and safety of our Indvidual's within the homes. |
06/09/2023
| Implemented |
| 6400.77(b) | The first aid kit did not contain tweezers. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | Direct care staff and the program coordinator were retrained on the importance of ensuring that A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. The first aid kit was updated, and components restocked and currently has a tweezer and all components available as of 5/23/23. The program coordinator was also retrained on the home biweekly checklist and the importance of utilizing it to ensure health and safety of our Indvidual's within the homes. |
06/09/2023
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.73(b) | The railing on the back porch was not secured. | Each porch that has over an 18-inch drop shall have a well-secured railing. | The rental property landlord (BJ) owner was contacted via text by the program coordinator, and the railing was secured by the landlord¿s handy man. To prevent further occurrence, the home checklist/oversight will be completed on a monthly basis which will include checking the railings. |
06/29/2019
| Implemented |
| 6400.101 | A dresser was found blocking an unoccupied bedroom on the 2nd floor. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Dresser was moved from in front of the closet on 6/27/19 by the program coordinator and no obstruction remained.
At the July staff meeting 7/29/19, staff ¿ will be retrained on the proper furniture placement and how to avoid hazards/obstructions throughout the home, even if the area is unoccupied (i.e.- bedroom) |
06/27/2019
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.110(e) | The smoke detectors on the first and second floor were not interconnected. | 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. | 1.The smoke detectors on the second and third floor were not interconnected at the Snyder residence, which is a requirement for homes with three or more stories.
2. Corrective action - install/Replace with Interconnected Smoke detectors
2a.Based on assessment of current smoke detectors , new interconnected smoke detectors will be purchased and installed at he Snyder residence.
Staff responsible - Tracy Chiyka (Complete by June 12, 2018)
3. Corrective action - Complete Fire Drill ( Snyder)
3a.Once the smoke detectors are installed a fire drill will be completed in order to test that it is in compliance and functions as specified.
Staff responsible - Tracy Chiyka ( complete by June 12, 2018)
4. Corrective action - Training
4a. All staff that are assigned to the Snyder property will be trained on the regulation that identifies that a home with three or more stories should have interconnected fire alarms. They will also be aware/trained on the follow up steps for notification if the alarms are not in compliance with this.
Staff responsible - Tracy Chiyka ( completion date June 29, 2018)
5. Long term plan - staff will continue to complete fire drills on a monthly basis and will report any and all concerns including if the fire alarms appear that they are not interconnected |
06/12/2018
| Implemented |
| 6400.141(c)(11) | Individual #1's physical examination dated 4/5/18 did not include an assessment of health maintenance needs including medication regimen and blood work. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | 1.Individual#1 physical examination dated 4/5/18 did not include an assessment of health maintenance needs including medication regimen and blood work.
2. Corrective action - Update Physical Examination From
2a . Individual #1 will attend a follow up exam with his Primary care physician and the PCP will provide assessment of his health management needs that include medication regimen and blood work.
Staff responsible - Tracy Chiyka ( completed by June 29,2018)
3. Long term plan
3a. On a quarterly basis the Director and lead program specialist will review medical records for 10% of the total individuals residing within all the CareSense living homes. Individual Records reviewed would include - physicals, PPD's and medical appointments for accuracy and timeliness and compliance. Initial review will be initiated in the month of June 2018.
Staff responsible - Terri-Ann Cooke & Lorena Leija ( Completion June 29,2018) |
06/29/2018
| Implemented |
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