| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.181(e)(6) | Individual #2's assessment completed 6/01/2023 states the individual uses poisonous materials safely. Individual #2's individual support plan, last updated 12/29/2023, states all sharp objects and poisons are locked at all times in the home and it is unclear if the individual understands the definitions of poisonous substances. | The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | On 1/5/24, an ISP update was requested from the SC. Please see supporting documents. ABDD reformatted the assessment to eliminate yes/no questions and using a narrative to provide more information. This template will be used across the agency moving forward, and the individuals was updated. Please see supporting documents. The ISP was updated with the requested revisions on 1/16/24. Please see supporting documents. |
01/18/2024
| Implemented |
| 6400.166(a)(11) | On 1/04/2024 Individual #2's January 2024 medication administration record did not include the diagnosis or purpose for any of the prescribed medications. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | The MAR has been updated to include the purpose for each medication. Please see supporting documents. |
01/18/2024
| Implemented |
| 6400.167(a)(1) | On 1/04/2024, Individual #2's January medication administration record documented that staff failed to administer Individual #2s' Onetouch Verio Test Strip, "to test 1 strip by miscellaneous route four times daily before meals and nightly" and Onetouch Verio Flex System, "use as directed, 1/01/2024, 1/02/2024, and 1/03/2024 at 4:00PM. | Medication errors include the following: Failure to administer a medication. | The on-call personnel were provided an agency schedule which shows the medication times for each home. This includes additional information for when JH is scheduled for blood sugar monitoring and insulin administration. Please see supporting documents. |
01/18/2024
| Implemented |
| 6400.195(b) | Individual #1's behavior support component of the individual plan was reviewed by the human rights team 2/21/2023 and then again 8/29/2023. | The behavior support component of the individual plan shall be reviewed and revised as necessary by the human rights team, according to the time frame established by the team, not to exceed 6 months between reviews. | The Director of Behavioral Services has been retrained on meeting the 6-month timeframe when completing behavior plan updates. Please see attached documents. |
01/18/2024
| Implemented |