Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.65 | There was no ventilation(mechanical or window) in the bathrooms. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| On 4/11/2022, the mechanical ventilation systems were serviced and cleaned thoroughly. It is now operating properly. Please refer to attachments 1 and 2 |
04/11/2022
| Implemented |
6400.82(f) | There was no trash receptacle in Individual #1's bathroom in his bedroom. It was replaced during the inspection. | 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. | The trash receptacle was replaced during the inspection, as it was removed by staff during cleaning. |
04/11/2022
| Implemented |
6400.111(c) | There was no fire extinguisher in the kitchen. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | A Fire extinguisher was purchased and placed in the kitchen under the sink. Please refer to attachment 3 |
04/11/2022
| Implemented |
6400.141(c)(12) | On the Annual Physical Exam for Individual #1 dated 3/21/22 the physical limitations portion was omitted. | The physical examination shall include: Physical limitations of the individual. | The physical has been returned to the physician for correction. Please refer to attachment 4 |
04/11/2022
| Implemented |
6400.141(c)(14) | Information pertinent to diagnosis in case of emergency was left blank on the Annual Physical Exam for Individual #1 dated 3/21/22. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The physical has been returned to the physician for correction. Please refer to attachment 4 |
04/11/2022
| Implemented |
6400.181(c) | The assessment dated 6/23/21 for Individual #1 did not indicate what the assessment was based on such as instruments, interviews, progress notes and observations used. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | The Basis of assessment has been completed and signed by the program specialist and participant. Please refer to attachment 10. |
04/11/2022
| Implemented |