| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(e) | According to the written fire drill record submitted for the last 12 months, there were no sleep fire drills held during the 7-month time period from April 2022 to October 2022. | A fire drill shall be held during sleeping hours at least every 6 months. | Sleep fire drill was successfully completed on 11/23/2022 (to be submitted). |
11/23/2022
| Implemented |
| 6400.141(c)(4) | Individual #1's physical examination, completed on 5/5/22, includes a hearing screening. Individual #1's physical examination, completed on 5/4/21, indicates that neither their hearing had been assessed, nor any physician's recommendations had been given. Their record does not include any completed audiologist examinations in 2021. Therefore, compliance could not be measured. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Physical exam requirement were reviewed with the Program Director during the IDD Residential Team meeting on 11/18/2022. |
11/18/2022
| Implemented |
| 6400.181(e)(5) | Individual #1's assessment, completed on 9/23/22, does not address their ability to self-administer medications. | The assessment must include the following information: The individual's ability to self-administer medications. | The Program Specialist created an addendum to Individual #1's assessment on 11/22/2022. The addendum (to be submitted) addressed the individual's ability to self-administer medications, and will be shared with all ISP team members and direct support staff. |
11/22/2022
| Implemented |
| 6400.181(e)(6) | Individual #1's assessment, completed on 9/23/22, does not address their ability to safely use or avoid poisonous materials. | The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | The Program Specialist created an addendum to Individual #1's assessment on 11/22/2022. The addendum (to be submitted) addressed the individual's ability to safely use or avoid poisonous materials when in the presence of poisonous materials, and will be shared with all ISP team members and direct support staff. |
11/22/2022
| Implemented |
| 6400.181(e)(7) | Individual #1's assessment, completed on 9/23/22, does not address their knowledge of and ability to quickly sense and move away from dangerous heat sources. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | The Program Specialist created an addendum to Individual #1's assessment on 11/22/2022. The addendum (to be submitted) addressed the individual's knowledge of and ability to quickly sense and move away from dangerous heat sources, and will be shared with all ISP team members and direct support staff. |
11/22/2022
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's assessment, completed on 9/23/22, does not address their level 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.
| The Program Specialist created an addendum to Individual #1's assessment on 11/22/2022. The addendum (to be submitted) addressed the individual's level of financial independence, and will be shared with all ISP team members and direct support staff. |
11/22/2022
| Implemented |
| 6400.181(e)(13)(viii) | Individual #1's assessment, completed on 9/23/22, does not address their ability to manage personal 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. | The Program Specialist created an addendum to Individual #1's assessment on 11/22/2022. The addendum (to be submitted) addressed the individual's ability to manage personal property, and will be shared with all ISP team members and director support staff. |
11/22/2022
| Implemented |
| 6400.181(e)(14) | Individual #1's assessment, completed on 9/23/22, does not address their knowledge of water safety and ability to swim. | 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. | The Program Specialist created an addendum to Individual #1's assessment on 11/22/2022. The addendum (to be submitted) addressed the individual's knowledge of water safety and ability to swim, and will be shared with all ISP team members and direct support staff. |
11/22/2022
| Implemented |
| 6400.32(r) | Individual #1's bedroom door was observed without a lock during the physical-site inspection on 11/9/22. Individual #1's record does not include documentation of their declination of a bedroom door lock or their incapacity to decide regarding this matter. | An individual has the right to lock the individual's bedroom door. | Individual Rights, Responsibilities, & Review Attestation document (ID-225A - to be submitted) has been updated to reflect the individual's declination of a bedroom door lock or their incapacity to decide regarding this matter. |
12/31/2022
| Implemented |
| 6400.169(a) | Medication Administration Trainer #1 completed Program Specialist #2's annual medication practicum on 5/31/22. Medication Administration Trainer #1's certification from the Department had expired on 5/23/22 and was renewed on 6/22/22. Program Specialist #2 passes medications. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | Program Specialist #2's annual medication practicum was repeated on 11/23/2022 (to be submitted). |
11/23/2022
| Implemented |