| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(b) | Surfaces are not free of hazards. The ceramic around the drain in the bathtub is rusted and has sharp edges presenting a hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | On 12/14/2023, the owner of the company restored the porcelain around the drain with Epoxy Porcelain Sealant. The surface is as smooth as the rest of the tub and is free from rust. |
12/14/2023
| Implemented |
| 6400.112(c) | The written fire drill record for fire drills conducted on 12/10/22 and 5/9/23 did not include whether the fire alarm or smoke detector was operative. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | The staff member responsible for not completing all aspects of the fire drill correctly was retrained by our Fire Safety Trainer on 12/18/2023. Additionally, all staff were retrained 12/26/2023 on the importance of completing fire drills with fidelity and trained on the new Fire Drill Form. |
12/26/2023
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination dated 5/5/23 did not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | All staff was retrained on the Physical Form and the training highlighted the need to have the doctor complete all sections of the form and that no sections should be left blank. Even though typically, Residential Supervisors take Individuals for their annual physicals, we retrained all staff as it could fall to any of them. We also would have liked to return to the PCP and ask them to complete the information, but this is a unique situation in that this Individual was incarcerated before coming directly to us so the doctor that completed the physical is not available to us. |
12/28/2023
| Implemented |
| 6400.151(a) | Staff #1 was hired on 1/6/23. Staff #1 did not have a physical examination completed within 12 months prior to employment. Staff #1's physical examination was completed on 1/10/23. | 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. | CEO , Program Specialist, and Owner reviewed regulation 151(a) to fully understand it. It was highlighted that 12 months prior to hire means before the first date a staff member would be paid NOT prior to working with Individuals as we had originally interpreted it to mean. In the past it has been our practice to begin orientation trainings before having the physical and/or TB, but never allowed contact with Individuals before doing so. We understand now that this was our misinterpretation and we will not even hire anyone until they show evidence of the requirement. |
12/18/2023
| Implemented |
| 6400.181(e)(4) | Individual #1's assessment dated 7/11/23 did not address Individual #1's need for supervision. The section that addressed supervision was from another individual's assessment. | The assessment must include the following information: The individual's need for supervision.
| Program Specialists was informed by the Executive Director of her negligence in completing the Annual Assessment. She then made all corrections necessary to the Assessment. |
12/13/2023
| Implemented |
| 6400.181(e)(14) | Individual #1's annual assessment dated 7/11/23 did not include Individual #1's ability to swim. The page that addressed this area was from another individual's assessment. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | Program Specialists was informed of her negligence in completing the Annual Assessment. She then made all corrections necessary to the Assessment. |
12/13/2023
| Implemented |