| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | There were several unlocked poisons found throughout the home including two Clorox bleaches, one container of laundry beads, all-purpose spray, and a Tub & Tile Repair kit, which contains several poisonous chemicals.
Champagne was also found unlocked in the home. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Clorox bleaches spray and tub kit was immediately removed and stored in a designated locked cabinet in the basement. Staff |
11/17/2022
| Implemented |
| 6400.64(a) | A substance consistent with mice droppings were present in areas where food is also stored. | Clean and sanitary conditions shall be maintained in the home. | The Director assigned Viking pest control to inspect the house for any traces of mice |
11/17/2022
| Implemented |
| 6400.66 | Several exits to the home lack adequate lighting. This includes the exit to the balcony off the second floor, as well as the main entrance of the home. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Additional lights were installed on Exit to the balcony second floor, Main entrance, basement entrance. A picture exhibits 6, 7, 8 would be sent as proof of the installation |
11/22/2022
| Implemented |
| 6400.66 | The closet light in an upstairs bedroom is not able to be turned on or off easily as the pull string is wedged between two boards. This requires more than average pressure to control the power to operate the light and possibly can break the string. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The upstairs closest light was removed and replaced on 11/22/2022. |
11/22/2022
| Implemented |
| 6400.67(b) | A standing lamp is being used for a coat rack that still has light bulb attached. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Director got our client consent to agree to relocate the Standing lamp into a storage. It was moved out his room on 11/17/22 |
11/17/2022
| Implemented |
| 6400.71 | There were no emergency telephone numbers listed near any of the phones in the home. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| The emergency telephone numbers frame been rehung on the wall next to phone. To be sent on picture exh 9 |
11/17/2022
| Implemented |
| 6400.72(b) | The door jam in the bedroom belonging to Individual #1 is broken. | Screens, windows and doors shall be in good repair. | The door jam in Individual No 1 room was replaced on 11/30/2022. Pic Exh. 10 as proof |
11/30/2022
| Implemented |
| 6400.72(b) | The top of the door frame of the second-floor exit is bent causing the door not to open properly. | Screens, windows and doors shall be in good repair. | The door top frame of second floor exit was modify and repaired on 11/22/2022 |
11/22/2022
| Implemented |
| 6400.73(a) | The third-floor interior railing was loose and poses a falling hazard. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | The 3rd-floor interior railing was re-tightened on 11/22/2022 |
11/22/2022
| Implemented |
| 6400.73(b) | There was secondary fencing on second level exterior balcony/handrail only secured with zip ties on exterior second floor balcony. | Each porch that has over an 18-inch drop shall have a well-secured railing. | The zip ties were for flower fix. And all fixing railing were re-inspected to be intact |
11/30/2022
| Implemented |
| 6400.74 | The exterior steps are extremely steep and should have a non-slip surface when exiting the building. | Interior stairs and outside steps shall have a nonskid surface.
| There is ongoing renovation to be completed later in the day today to add nonskid surface to existing steps |
12/02/2022
| Implemented |
| 6400.76(a) | The headboards in both bedrooms are unstable and can be easily swayed with little pressure. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Beds frames were retightened on . |
11/30/2022
| Implemented |
| 6400.80(b) | The exterior conditions of the home contain several large items of garbage and construction debris. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The rear exterior of the home with construction/garbage debris is now totally removed as at 11/30/2022. |
11/30/2022
| Implemented |
| 6400.144 | Regarding Medication review for Individual #1: The medication Methylpenid 36 mg tab blister pack was empty and there were no refills present. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Methypenid 36 mg a national shortage aware by individual psychiatrist. Rehoboth Inc director and Nurse prior got the psychiatrist to change the prescription prior to visit. Evidence by Doc Exh 10 of his psychiatrist visit. Another prescribed now in place. |
11/18/2022
| Implemented |
| 6400.144 | Regarding Medication review for Individual #2: The medication Invega Trinza 819 mg Injection was not present at the time of inspection. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Invega Trinza 819 mg injection. A one in 3 months injection only deliver by pharmacy few days before due date. The Nurse on 11.17.22 train all staff to be well informed to provide information regarding injection information of its availability. |
11/17/2022
| Implemented |
| 6400.32(h) | The bedroom door belonging to Individual #1 does not lock. | An individual has the right to privacy of person and possessions. | The door repair was completed on 11/30/2022. |
11/30/2022
| Implemented |
| 6400.163(g) | Medications for both Individuals were stored together in one plastic bag in a cabinet with food and dishes. | Prescription medications shall be stored in an organized manner under proper conditions of sanitation, temperature, moisture and light and in accordance with the manufacturer's instructions. | The cabinet was fully cleaned on 11/17/2022 |
11/17/2022
| Implemented |
| 6400.163(h) | Regarding the medication review for Individual #2: Clonazapam was present at the time of inspection but was not listed on the MAR. CEO states he believes this medication was discontinued. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | The clonazepam was discontinued. It is now taken to police station for discard with pic evidence to sent |
12/02/2022
| Implemented |
| 6400.166(a)(2) | The prescriber information is not included on the MAR for both Individuals. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | The prescriber information is now included on the MAr to be show on Exh 12 |
11/30/2022
| Implemented |