| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(c) | A fire drill for the month of November 2022 was provided. The time of the drill was 4:30pm and the evacuation time was 44 seconds. However, the date was not listed on this form | 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. | Fire drill documentation redone to state "Month", "Date", and "Year" instead of "Day", "Month", and "Year".
Updated fire drill attached. |
| Implemented |
| 6400.181(e)(13)(iii) | The individual's assessment dated 11/10/2022 did not include the indiviudals progress and growth over the last 365 days and current level in the area of.residential living. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | Individual's assessment dated 11/10/2022 was updated to include progress and growth over the last 365 days and current level in the following areas: Residential Living, Personal Adjustment, Community Integration, Socialization, Recreation, Managing property, and Financial independence. Residential team to have an additional reviewer (either a Program Specialist or Program Manager) read all Residential Assessments going forward to ensure all information is included. |
02/27/2023
| Implemented |
| 6400.181(e)(13)(iv) | The individual's assessment dated 11/10/2022 did not include the indiviudals progress and growth over the last 365 days and current level in the area of personal ajustment | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | Individual's assessment dated 11/10/2022 was updated to include progress and growth over the last 365 days and current level in the following areas: Residential Living, Personal Adjustment, Community Integration, Socialization, Recreation, Managing property, and Financial independence. Residential team to have an additional reviewer (either a Program Specialist or Program Manager) read all Residential Assessments going forward to ensure all information is included. |
02/27/2023
| Implemented |
| 6400.181(e)(13)(v) | The individual's assessment dated 11/10/2022 did not include the individuals progress and growth over the last 365 days and current level in the area of. socialization | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | Individual's assessment dated 11/10/2022 was updated to include progress and growth over the last 365 days and current level in the following areas: Residential Living, Personal Adjustment, Community Integration, Socialization, Recreation, Managing property, and Financial independence. Residential team to have an additional reviewer (either a Program Specialist or Program Manager) read all Residential Assessments going forward to ensure all information is included. |
02/27/2023
| Implemented |
| 6400.181(e)(13)(vi) | The individual's assessment dated 11/10/2022 did not include the indiviudals progress and growth over the last 365 days and current level in the area of.recreation. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | Individual's assessment dated 11/10/2022 was updated to include progress and growth over the last 365 days and current level in the following areas: Residential Living, Personal Adjustment, Community Integration, Socialization, Recreation, Managing property, and Financial independence. Residential team to have an additional reviewer (either a Program Specialist or Program Manager) read all Residential Assessments going forward to ensure all information is included. |
02/27/2023
| Implemented |
| 6400.181(e)(13)(vii) | The individual's assessment dated 11/10/2022 did not include the indiviudals progress and growth over the last 365 days and current level in the area of.financial independence. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| Individual's assessment dated 11/10/2022 was updated to include progress and growth over the last 365 days and current level in the following areas: Residential Living, Personal Adjustment, Community Integration, Socialization, Recreation, Managing property, and Financial independence. Residential team to have an additional reviewer (either a Program Specialist or Program Manager) read all Residential Assessments going forward to ensure all information is included. |
02/27/2023
| Implemented |
| 6400.181(e)(13)(viii) | The individual's assessment dated 11/10/2022 did not include the indiviudals progress and growth over the last 365 days and current level in the area of. managing property. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | Individual's assessment dated 11/10/2022 was updated to include progress and growth over the last 365 days and current level in the following areas: Residential Living, Personal Adjustment, Community Integration, Socialization, Recreation, Managing property, and Financial independence. Residential team to have an additional reviewer (either a Program Specialist or Program Manager) read all Residential Assessments going forward to ensure all information is included. |
02/27/2023
| Implemented |
| 6400.181(e)(13)(ix) | The individual's assessment dated 11/10/2022 did not include the individual's progress and growth over the last 365 days and current level in the area of.community integration. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration. | Individual's assessment dated 11/10/2022 was updated to include progress and growth over the last 365 days and current level in the following areas: Residential Living, Personal Adjustment, Community Integration, Socialization, Recreation, Managing property, and Financial independence. Residential team to have an additional reviewer (either a Program Specialist or Program Manager) read all Residential Assessments going forward to ensure all information is included. |
02/27/2023
| Implemented |
| 6400.32(r)(5) | At the time of the inspection the staff did not have a key to access the individual's bedroom once the door was locked. | Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door. | Copies of bedroom keys were made and labeled. One labeled copy of each key was put on a lanyard for staff to carry during shift. Another labeled copy of each key was hung in the locked medication cabinet of each home. |
03/31/2023
| Implemented |
| 6400.165(c) | Individual #1 is prescribed Polyethylene Glycol Powder. At the time of inspection, the pharmacy label directed to give daily and to stop if diarhea occurs. The medication administration record directed to dissolve in 8oz of liquid and drink if there is no bowel movement in 2 days. Due to the conflicting directions, it was unable to be determined if the medication is being administered as prescribed. Individual #1 is also prescribed mineral oil rectal enema. The pharmacy label directed to be administered in the morning and before bed. However, the MAR directed to administer once as needed for constipation. Due to the conflict of instructions, it is unable to be determined if the medication was administered as prescribed. | A prescription medication shall be administered as prescribed. | Individual #1's medications were reordered. MAR to match Polyethylene Glycol Powder and Enema were were written and placed in Individual's Medication Administration Log. |
02/27/2023
| Implemented |