Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.81(i) | The window in Individual #9's bedroom did not have curtains, drapes, blinds, or shutters. | Bedroom windows shall have drapes, curtains, shades, blinds or shutters. | IHRS will ensure that all individuals have blinds, curtains, drapes or shutters on their bedroom windows. Program Specialist will ensure that individual #9 has this requirement met. |
09/15/2020
| Implemented |
6400.101 | The door leading into the garage was had a double-key lock. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The double key lock is being removed to ensure that all passageways are unobstructed. IHRS is completing an audit of all homes to ensure there are no other issues of this nature. |
09/15/2020
| Implemented |
6400.141(c)(9) | Individual #5 had a prostate exam on 11/7/2018. He didn't have another prostate exam until 7/2/2020, which exceeds the annual requirement. | The physical examination shall include: A prostate examination for men 40 years of age or older. | Program Specialist will be re-trained on annual appointment requirements for clients. IHRS will conduct routine audits to ensure compliance. |
09/15/2020
| Implemented |
6400.141(c)(11) | Bloodwork for Individual #5 was to be completed before 4/2/2020 and was ordered again on 7/2/2020. There is no documentation of any bloodwork being completed. Staff confirmed this was not completed and reported it was being completed the next day. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | Bloodwork was completed. Program Specialist and staff will be retrained on health matienence needs and ensuring that all appropriate follow-up is completed. |
09/15/2020
| Implemented |
6400.141(c)(14) | This section was blank on Individual #5's physical exam dated 7/2/2020. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | IHRS will send physical back to PCP for proper completion. IHRS will audit all physicals to ensure that all proper and necessary information is listed. |
09/15/2020
| Implemented |
6400.34(a) | Individual #5 was informed of his rights on 12/26/2018. He wasn't informed of his rights again until 3/20/2020, which exceeds the annual requirement. | 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. | IHRS will retrain Program Specialists on protocols regarding explaining client rights. All individuals entering a residential program will have client rights reviewed the day of admission and annually thereafter. |
09/15/2020
| Implemented |
6400.213(1)(i) | The photo in Individual #5's record was not dated. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.
213 (1)vi: A current, dated photograph. | IHRS compliance department in conjunction with the Program Specialist will ensure that all photos are dated and current. IHRS will conduct a file audit to ensure that this is completed. |
09/15/2020
| Implemented |