| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(e) | The trash can in the kitchen, which exceeded 18 inches in height, did not have a lid at time of inspection. | Trash receptacles over 18 inches high shall have lids. | Upon knowledge that a trash can was missing a lid, admin purchased a trash can with a lid for replacement the same day. |
07/23/2021
| Implemented |
| 6400.67(a) | A cabinet in the second story bathroom had a door that was loose, hanging on at an angle by one of two mounting fixtures when in the open position.
In the living room, there was an empty area where a curtain rod holder was previously affixed to the wall, exposing screw holes.
There were exposed screw holes and anchors in the wall outside of the master bedroom door on the third floor. | Floors, walls, ceilings and other surfaces shall be in good repair. | Upon knowledge that the cabinet was loose a repair guy was called to fix the cabinet the same day. |
07/23/2021
| Implemented |
| 6400.72(a) | The front window in the basement and two of the windows in the master bedroom completely lacked window screens. A window screen in the second story spare bedroom was bent in such a way that it was not fully secure in the window. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Upon discovery of the missing and damaged screens, the repair guy was called to replace the missing screens and damaged ones. |
07/23/2021
| Implemented |
| 6400.80(b) | There were several pieces of trash in the back yard, including an empty pizza box, Styrofoam plate, scraps of paper, and an empty plastic water bottle. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | Upon discovery of unmaintained ground admin cleaned up the trash in the yard . |
07/23/2021
| Implemented |
| 6400.82(f) | There was no toilet paper available in the second story 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. | Upon discovery of non compliance with the toilet paper missing out the bathroom, admin went to cleaning closet and replaced the missing toilet paper. |
07/23/2021
| Implemented |
| 6400.141(c)(9) | At the time of inspection there was no documentation of current complete prostate exam for Individual #1 | The physical examination shall include: A prostate examination for men 40 years of age or older. | Upon knowledge of a missing prostate exam , admin called individual #1 PCP to set a appointment for a prostate exam. |
07/16/2021
| Implemented |
| 6400.151(a) | A staff member did not have Staff Physical Exams occur within the established regulatory time frame. Staff #1 was hired on 06/23/2020, but did not have a physical completed until 06/19/2021. | 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. | Due to Covid Staff #1 did not have physical upon new hire , a physical was completed but late |
07/23/2021
| Implemented |
| 6400.32(s)(2) | There was a child safety lock affixed to the interior door knob of the front door to the home. Staff on site stated that Individual 1 is unable to open the door when this device is in place; this device does not allow Individual 1 easy and immediate access in the case of an emergency. | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. | The lock has been removed immediately from the door knob upon discovery. |
07/29/2021
| Implemented |
| 6400.166(b) | There were no initials in Individual #1's July 2021 Medication Administration Record (MAR) for the 8:00am dose of Docusate Sodium 100mg on 07/08/2021 to record administration of the medication. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Upon discovery of missing initials admin checked the log to ensure that the medication was in fact given, the staff member who admin the medication was called in to complete the MAR with their initials for completion |
07/23/2021
| Implemented |
| 6400.192 | Current BSP reflects that Individual #1 is on a restrictive plan which includes keeping the knives locked in his residence. At the time of inspection this plan was not being implemented as written. | The home shall develop and implement a written policy that defines the prohibition or use of specific types of restrictive procedures, describes the circumstances in which restrictive procedures may be used, the staff persons who may authorize the use of restrictive procedures and a mechanism to monitor and control the use of restrictive procedures. | The agency BSP plan was not followed due to the incompletion of the approval of the restrictive plan. The plan on site was from the other agency where the individual use to reside |
07/23/2021
| Implemented |