| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.81(h) | The window in Individual #10's room is covered with a dark film for privacy as Individual #10 will pull the blinds down from the window. The dark film prevents Individual #10 from having a view to the outside. | Each bedroom shall have at least one exterior window that permits a view of the outside. | IHRS will remove the film from the window. IHRS will find alternate way to provide curtains and or drapes. IHRS will ensure that individual has view from bedroom window. |
09/15/2020
| Implemented |
| 6400.141(c)(10) | Individual #1 is diagnosed with Hepatitis C, which is a communicable disease. His physical exam dated 6/24/2020 states he is free from communicable disease and does not list specific precautions that should be taken to prevent the spread of the disease to other individuals. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | IHRS received paperwork from PCP indicating that this individual does not have a communicable disease. IHRS will forward paperwork to Licensing. |
09/15/2020
| Implemented |
| 6400.181(a) | Individual #1 had an assessment completed on 1/7/2019. He didn't have another assessment completed until 6/23/2020, which exceeds the annual requirement. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | IHRS will re-train all Program Specialists on proper time lines in which the Program Assessment should be mailed. IHRS will conduct audit to ensure that all assessments are being provided within the proper timeframe. |
09/15/2020
| Implemented |
| 6400.181(e)(1) | Functional strengths, needs and preferences were not assessed on Individual #1's assessment dated 6/23/2020. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | IHRS compliance department in conjunction with the Program Specialist are checking all assessments to make sure they address the functional needs, strengths and preferences of the individual. Individual #1's assessment will be updated. |
09/15/2020
| Implemented |
| 6400.181(e)(2) | Likes, dislikes and interests were not assessed on Individual #1's assessment dated 6/23/2020. | The assessment must include the following information: The likes, dislikes and interest of the individual. | IHRS compliance department in conjunction with the Program Specialist are checking all assessments to make sure they address the likes and dislikes of the individual. Individual #1's assessment will be updated. |
09/15/2020
| Implemented |
| 6400.181(e)(13)(viii) | Progress and growth in the area of managing personal property was not assessed on Individual #1's assessment dated 6/23/2020. | 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. | ¿ IHRS compliance department in conjunction with the Program Specialist are updating the Program Assessment to include progress over the last year. IHRS will check all other Program Assessments to ensure that they indicate progress as well. Compliance will review all Program Assessments before they are sent as a completed document.
o Community Integration
o Personal Property
o Recreation
o Financial Independence
o Socialization
o Personal Adjustment
o Activities of Daily Living
o Motor and communication skills
o Health |
09/15/2020
| Implemented |
| 6400.181(e)(13)(ix) | Progress and growth in the area of community integration was not assessed on Individual #1's assessment dated 6/23/2020. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration. | IHRS compliance department in conjunction with the Program Specialist are updating the Program Assessment to include progress over the last year. IHRS will check all other Program Assessments to ensure that they indicate progress as well. Compliance will review all Program Assessments before they are sent as a completed document.
o Community Integration
o Personal Property
o Recreation
o Financial Independence
o Socialization
o Personal Adjustment
o Activities of Daily Living
o Motor and communication skills
o Health |
09/15/2020
| Implemented |
| 6400.181(f) | Individual #1's ISP meeting was held on 2/28/2020. His assessment wasn't sent to his team until 6/23/2020. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | IHRS will re-train all Program Specialists on proper time lines in which the Program Assessment should be mailed. IHRS will conduct audit to ensure that all assessments are being provided within the proper timeframe. |
09/15/2020
| Implemented |