| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | Blinds located in the bedroom of individual 5 are in need of repair. | Floors, walls, ceilings and other surfaces shall be in good repair. | New blinds were ordered and installed by Maintenance manager on 7/20/23. |
10/09/2023
| Implemented |
| 6400.141(c)(14) | For individual 5, the physical does not answer the "info pertinent to diagnosis in the event of an emergency" | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | individual 5 was scheduled for annual physical on 8/14/23 where it was documented that 911 shall be called in case of an emergency. |
08/14/2023
| Implemented |
| 6400.181(e)(14) | For individual 6, the assessment does not report on his functional ability to swim, only that he enjoys swimming and would need staff supervision. The ISP reports that he CANNOT swim, would likely not go in water over his head, and would need staff supervision. The assessment should be updated to reflect the information shared in the ISP. A suggested addition would be that he requires a life jacket while in deeper bodies of water. | 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. | On 7/7/23 annual assessment form used by agency was updated to include a statement under water safety that requires the assessor to answer "can the individual swim (circle one) yes or no". On 7/7/23, an addendum was added to individual 6's assessment which states that NO he cannot swim. The addendum was mailed to the individual, his mother, and his supports coordinator along with a letter explaining that an addendum was made to his annual assessment. |
07/07/2023
| Implemented |
| 6400.52(a)(1) | Staff 2 completed only 23/24hrs of required annual training
Staff 1 completed 23.5/24hrs of required annual training | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | HAP¿s training year runs from January to December. For the 2023 training year, staff 1 currently has 21 hours and staff 2 has 26. Both are scheduled for 8 hours of training on 10/23/23 in the areas of reporting/preventing abuse and positive behavior supports. If either should miss this training, they will be assigned equivalent (both in hours and content) trainings in the college of direct supports. |
10/09/2023
| Implemented |
| 6400.52(b)(1) | Titled 2022 CEO (staff 3) did not complete the required 12hrs of annual training; the newly titled CEO was appointed 5/1/23 | The following shall complete 12 hours of training each year: Management, program, administrative and fiscal staff persons. | As on 10/7/23, the new CEO has 15 hours of training. He is scheduled for 6 hours of training on 10/23/23 in the areas of reporting and preventing abuse. |
10/07/2023
| Implemented |
| 6400.213(1)(i) | The face sheet is missing individual 6's religious affiliation, and height and weight. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | A new face sheet was created in therap on 9/27/23 for individual 6 which includes all of the required information. |
09/27/2023
| Implemented |