| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(4) | Individual #1 had an annual vision examination completed on 09/13/21 and then again on 11/03/22. This exceeds the annual requirement. [Repeat violation 09/21/22 et. al] | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | All program specialists will be retrained on the need to follow the regulatory requirements for annual medical appointments. This training will be conducted by the Associate Director of Residential Services and/or the Director of Program Operations. [Additional information received from the agency via email on 10/4/23: Program Specialists will be trained in the requirements of medical appointment documentation on or about 10/10/23. Program Specialists will document monthly reviews of individual medical appointments. The Director of Quality, or their designee, will conduct reviews of individual medical appointment documentation monthly. DPOC by HDKP, HSLS on 11/1/23]. |
09/26/2023
| Implemented |
| 6400.34(a) | Individual #1 was informed and explained their individual rights on 01/03/22, and then again on 02/10/23. This 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. | Mainstay will reinstate a process of distributing individual rights information to residential supervisors at the beginning of each calendar year so that the rights will be explained to all individuals receiving services on an annual basis. [Additional information received from the agency via email on 10/4/23: Training related to informing and explaining Individual Rights to individuals on an annual basis is scheduled to occur on or about 10/10/23. DPOC by HDKP, HSLS on 11/1/23]. |
09/26/2023
| Implemented |
| 6400.182(c) | Individual #1's most current assessment, dated 12/19/22, indicates that the individual self-administers medications; however, Individual #1's current ISP, dated 05/26/23, indicates the individual does not self-administer medications. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Program specialists will review assessments and ISPs for all individuals they are responsible for and check for discrepancies. If it is necessary to update an individual's ISP based on a recent assessment, the program specialist will email the individual's SC to request an update. Each time a new assessment is completed this review will occur. |
09/26/2023
| Implemented |
| 6400.195(b) | The behavior support component of the Restrictive Procedure Plan and Individual Support Plan for Individual #1, admission date 02/01/16, was reviewed on 01/05/23 and then again on 07/25/23. This exceeds the 6-months between reviews. | 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. | Mainstay's reconstituted human rights committee will resume meeting on a quarterly basis. The behavior support component of all restrictive procedure plans will be reviewed at each meeting. |
09/21/2023
| Implemented |