Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.67(a) | A ceiling tile in Individual #1's bedroom was warped and hanging lower then the rest of the ceiling tiles. | Floors, walls, ceilings and other surfaces shall be in good repair. | Ceiling tiles have been replaced in Individual #1's bedroom. See Attachment #51. |
10/09/2017
| Implemented |
6400.74 | The stairs on the side deck off of the side door are not equipped with non-skid surfaces. | Interior stairs and outside steps shall have a nonskid surface.
| Non-skid strips were applied to the stairs on the side of deck off the side door. See Attachment #50. |
10/09/2017
| Implemented |
6400.145(1) | The home did not have a written emergency medical plan that include the hospital or source of health care that will be used in an emergency. This was requested at the time of licensing. | The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. | A written emergency medical plan that included the hospital that will be used in an emergency was written on 10/16/17 by program specialist for individual #1. The other individuals¿ residing in the home (not included in the sample) emergency medical plans were reviewed for the inclusion of the hospital that would be used. The hospital they use was present on their plans. This review was completed by Program Specialist on 10/16/17. |
10/16/2017
| Implemented |
6400.145(2) | The home did not have a written emergency medical plan that include the method of transportation that will be used in an emergency. This was requested at the time of licensing. | The home shall have a written emergency medical plan listing the following: The method of transportation to be used. | A written emergency medical plan that indicated the method of transportation to be used for individual #1 was written on 10/16/17 by program specialist. Other individuals¿ (not included in this sample) emergency medical plans were reviewed for including the method of transportation to be used in the case of an emergency. They did not include the method of transportation. These emergency medical plans were updated to include the method of transportation by the program specialist on 10/16/17. |
10/16/2017
| Implemented |
6400.145(3) | The home did not have a written emergency medical plan that include an emergency staffing plan that will be used in an emergency. This was requested at the time of licensing. | The home shall have a written emergency medical plan listing the following: An emergency staffing plan. | A written emergency medical plan that indicates an emergency staffing plan was completed by program specialist on 10/16/17. Other individuals¿ (not included in this sample) emergency medical plans were reviewed for including the emergency staffing plan to be used in the case of an emergency. They did not include the emergency staffing plan. These emergency medical plans were updated to include the emergency staffing plan by the program specialist on 10/16/17. |
10/16/2017
| Implemented |
6400.216(a) | Individual #2's record information was found unlocked and unattended in the staff room. The staff door was unlocked. | An individual's records shall be kept locked when unattended. | A training memo was created and sent to direct support professionals indicating the regulation of all individuals records need to be locked when not attended. An individual record shall be kept locked when unattended. The individual and the individual's parent, guardian or advocate shall have access to the records and to information in the records. If the interdisciplinary team documents that disclosure of specific information constitutes a substantial detriment to the individual or that disclosure of specific information will reveal the identity of another individual or breach the confidentiality of persons who have provided information upon an agreement to maintain their confidentiality, that specific information identified may be withheld. See Attachment #22 |
10/20/2017
| Implemented |