| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(b) | On 3/24/23, there was a puddle of water at the bottom of the stairs in the basement of the home posing a slip and fall hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Maintenance Technician cleaned up the water in the basement, inspected the building exterior, and found a disconnected downspout which caused the water to accumulate in the basement. Maintenance Technician repaired the downspout. |
03/27/2023
| Implemented |
| 6400.72(a) | On 3/24/23, the windows, on the fourth floor of the home, did not have screens. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Maintenance Technician made new screens for all 4th floor windows and securely installed the screens so that they are fixed to the window frame. Now, the windows are securely screened while the window is open or closed. |
04/04/2023
| Implemented |
| 6400.110(f) | Individual #1's individual plan, last updated 1/31/2023, states the individual was diagnosed with bilateral hearing loss in 2018 and is prescribed hearing aids but chooses not to wear them. During the inspection conducted on 3/23/2023, the smoke detectors were not equipped so that the Individual #1 would be alerted in the event of a fire. | If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. | Program Specialist reviewed documentation and found the last documented audiology review for individual #1 was in 2018. Audiology appointment took place on 4/4/2023. Audiologist requested a bed shaker, but said strobes are not needed. Bed shaker was installed on 4/4/2023. |
04/04/2023
| Implemented |
| 6400.111(c) | There was not a minimum 2A-10BC rated fire extinguisher in the kitchen of the home. | 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). | Maintenance Technician replaced the kitchen fire extinguisher with a 2A 10BC rated fire extinguisher. |
03/24/2023
| Implemented |
| 6400.112(c) | The written fire drill records for the fire drills, held from 10/14/22 to 2/25/23, did not include problems encountered. | 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. | On 3/24/23 Maintenance Supervisor updated the LHC Fire drill form to include ¿Problems Encountered¿ and was made available to all service locations. All homes then completed a fire drill using the updated form on or before 3/31/23. |
03/31/2023
| Implemented |
| 6400.163(d) | On 3/23/23, there was an unlocked bottle of Equate Ibuprofen, 200mg, containing multiple unidentified pills in Individual #1's bedroom. The first aid kit, which is unlocked and accessible on the counter in the kitchen of the home contained Aspirin 325mg, Acetaminophen 325mg, and Diphenhydramine HCL 25mg. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | 3/24/23 VP Compliance removed all unlocked medications from Individual 1¿s possession and removed all medications contained in the unlocked first aid kit. 3/29/23 Program Specialist requested a list of OTC medications that individual 1 is allowed to self-administer when needed from primary care physician. Program Specialist also requested prescriptions for all OTC medications whether self-administered or staff administered. |
05/01/2023
| Implemented |