| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.81(k)(6) | There was no mirror in Individual #2's bedroom. | In bedrooms, each individual shall have the following: A mirror. | Program Manager and DSP's working at location will be re-trained in the above mentioned regulation. Mirror was purchased and placed in individual #2¿s bedroom. |
12/31/2023
| Implemented |
| 6400.104 | The most recent notification letter to the fire department is dated April 21, 2022, and does not contain current information; the letter states that there are three individuals residing in the home, but the current census is four. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Program Managers will be retrained on the above regulation. All fire department letters will be reviewed and updated by the Program Manager for all locations. Letters will be submitted to Quality Assurance and Regulatory Compliance Manager for review. |
12/31/2023
| Implemented |
| 6400.141(c)(4) | The annual physical examination that occurred on 3/15/2023 for Individual #1 did not include a hearing screening and there is no documentation that the Individual had a hearing screening from another provider or source. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | IHRS will contact the PCP to determine if a hearing screening is needed. Documentation will be attached to the physical in question. Program Manager and DSP's will be retrained on the responsibility of getting the physical completed and the responsibility of advocacy for clients during medical appointments. IHRS will review all client physicals to ensure that they meet regulatory compliance |
12/31/2023
| Implemented |
| 6400.144 | Health services shall be provided. Individual #1 had an annual appointment with an eye doctor on 4/12/2023 and the doctor recommended that the individual should see a specialist for a dilated fundus examination. The individual did see an eye doctor on 8/03/2023 for a new prescription for eyeglasses, but there is no record that the dilated fundus examination occurred. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| IHRS will contact original provider for referral for dilated fundus examination. Training on follow-up will occur with DSP that ran appointment and Program Manager overseeing the home. |
12/31/2023
| Implemented |
| 6400.34(a) | The individual rights statement that was reviewed with and signed off on by Individual #1 on 11/23/2022 was not complete and did not include the following rights: 32r1 to 32r5 (concerning bedroom door locks), and 32v, the provision that an individual's rights may only be modified to the extent necessary to mitigate a significant health and safety risk to the individual or others. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Program Manager will be retrained on the above cited regulation. Quality Assurance and Regulatory Compliance Manager will review current Individual Rights to ensure that all required information is present. All old forms will be removed from offices and electronic storage to ensure they are no longer used. Program Manager will meet with Individual #1 to review updated forms. |
12/31/2023
| Implemented |