| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency completed the self-assessement for the home on 9/17/13. The home's license expired on 3/20/14. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| When the agency receives the Certificate of Compliance, the expiration date will be used to plan self assessmemnts for the next twelve months. Program supervisors and program directors will conduct self inspections every four months with the final self inspection completed within three to six months prior to the certificate expriration date. |
07/01/2014
| Implemented |
| 6400.72(b) | The molding and framework is not finished on the window in the first floor bathroom. | Screens, windows and doors shall be in good repair. | The landlord was contacted regarding the finishing trimwork for the bathroom window and plans are to have this completed by July 21, 2014. Pictures will be forwarded for verification. A letter is being sent to the landlord by the executive director explaining the need to comply with state regulations to keep the home in good repair. When self inspections are completed by the program director, the landlord will be immediately notifed of unfinished repair projects and a deadlline will be negotatied for completion. If a safety hazard is an immediate issue the executive director will make sure the repair is completed immediately and will work out the details with the landlord after the fact. |
07/21/2014
| Implemented |
| 6400.77(b) | The home's first aid kit did not contain antiseptic. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | Antiseptic was purchased by program staff for the first aid kit on June 30, 2014. A receipt copy will be forwarded for verification. A checklist is being formulated by the program directors for facility program staff to complete monthly beginning August 2014, verifying that specific requlation requirements are being met for physical site and safety needs. This will be reviewed by the program supervisor prior to the end of each month and forwarded to the administrative office for review and approval of repair or purchase. Required items missing from the first aid kit will be replaced immmediately. The checklist will define what an acceptable antiseptic product will be supplied in the first aid kit. |
07/01/2014
| Implemented |
| 6400.181(f) | The assessment dated 2/20/14, for Individual #1, was not provided to all the team members by the program specialist. | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| A form distribution checklist is utilized by agency clerical personnel to determine the routing of specific documents. The form is current with regulation requirements and will be forwarded for verification. For prevention and correction purposes, both the clerical staff and program specialist will review outgoing documents to verify that the information is being sent to the correct team members and will utilize a cc: section as verification. |
07/01/2014
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not include the religious affiliation. | Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. | Individual records contain an identification data sheet that is updated or verified during self inspections. The program supervisor and program director will review the form to insure that all information has been completed. In cases when an individual does not identify a specific religious affiliation, a notation will be included on this form stating that the individual does not wish to provide a response to this question. The question will be posed at each annual individual support plan meeting and documentation of the answer will be maintained. The corrected form will be forwarded for verification. |
07/11/2014
| Implemented |