| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The oven has significant build up/scorched food on the door and floor and is need of cleaning. | Clean and sanitary conditions shall be maintained in the home. | The Operations Director cleaned the oven. |
| Implemented |
| 6400.76(a) | The door of the microwave is cracked/broken. It is taped but is need of repair or replacement. | Furniture and equipment shall be nonhazardous, clean and sturdy. | the Operations Director patched door crack. |
10/10/2023
| Implemented |
| 6400.81(k)(6) | There is no mirror in individual#1's bedroom. | In bedrooms, each individual shall have the following: A mirror. | the operations Director added mirror. |
10/10/2023
| Implemented |
| 6400.82(f) | The main hall bathroom did not have hand/paper towel (it was added while the inspector was present). | 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. | Hand towels and c-fold were added to the bathroom. |
10/09/2023
| Implemented |
| 6400.105 | The lint trap was full. It was cleared while the inspector was still at premises. | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| The lint trap was cleaned by Operations Director. |
10/10/2023
| Implemented |
| 6400.110(e) | The home does not have an interconnected smoke detector system, which is required based on the home's floorplan. | 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. | CEO researched handyman to wire. No luck but did research and found wireless interconnected. CEO ordered the alarms October 16th. |
10/31/2023
| Implemented |
| 6400.141(a) | The 2023 annual physical is completed past due the one-year requirement. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #1's physician was contacted to provide information pertinent to treatment and diagnosis. |
10/09/2023
| Implemented |
| 6400.141(c)(14) | The 2023 physical form does not answer the section "info pertinent to diagnosis in the event of an emergency." | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | A&K Management schedules and tracks completion of annual physicals so that primary care can complete them on time. In this instance, the physical had to be rescheduled and healthcare provider was unable to meet our request to complete the physical on time. Physical was completed and submitted 9/12/23. |
10/09/2023
| Implemented |
| 6400.151(c)(3) | Physical exam dated 2/22/23 does not include if staff member #1 was free of communicable disease- this was left blank. Tb test conducted 3/6/23 after date of hire 3/1/23. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | The section was missed on member #1 phyiscal. |
10/10/2023
| Implemented |
| 6400.50(a) | The training date(s) for staff member #1 were not provided for orientation training. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | Form was updated to ensure dates are included for each training topic. Training staff were retrained on how to complete the form properly. The dates were corrected to the best of our knowledge on the form that was missing. |
11/10/2023
| Implemented |
| 6400.165(g) | The provided psychotropic med reviews are incomplete specific to the regulation regarding the reason for the prescription, the need to continue the medication, and the necessary dosage (March and August 2023 met the requirements).
The psychotropic med reviews indicate that the individual receives monthly reviews (reasoning is not indicated). Given this frequency, the June 2023 review was not completed, based on the documentation provided at inspection. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Individual #2 saw his psychiatrist on 6/20/23. Documentation was obtained and added to the individual's file. |
11/10/2023
| Implemented |