| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(f) | Fire drills conducted from September 2021 through and including August 2022 utilized the front door as the exit route. The home has more than one exit route. | Alternate exit routes shall be used during fire drills. | Program Supervisors will train staff to ensure understanding of how to accurately and correctly complete fire drill documentation to avoid errors when documenting evacuation time. [Documentation of staff training, dated 1/26/23, related to alternating exit routes utilized during fire drills was received on 2/13/23 and reviewed 3/1/23. DPOC by HDKP, HSLS, on 3/8/23]. |
10/03/2022
| Implemented |
| 6400.52(c)(5) | Direct Services Worker #1, date of hire 8/1/2011, did not complete the following training topic for the annual training year 7/1/2021 to 6/30/22: The safe and appropriate use of behavior supports | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | The Director of Quality worked with program supervisors to assign required annual trainings with due dates to program staff in the agency's learning management system. Program supervisors review staff training completion and compliance at monthly staff meetings and follow-up with staff who haven't completed trainings as assigned. [Documentation of the annual training plan that includes Personal Information Profile Review, dated as completed on 8/16/21, and Crisis Intervention, dated as completed on 3/24/22, was received on 2/15/23 and reviewed 3/8/23. DPOC by HDKP, HSLS, on 3/8/23]. |
10/03/2022
| Implemented |
| 6400.52(c)(6) | Direct Services Worker #1, date of hire 8/1/2011, did not complete the following training topic for the annual training year 7/1/2021 to 6/30/22: Implementation of the individual plan | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | The Director of Quality worked with program supervisors to assign required annual trainings with due dates to program staff in the agency's learning management system. Program supervisors review staff training completion and compliance at monthly staff meetings and follow-up with staff who haven't completed trainings as assigned. [Documentation of the annual training plan that includes Individual ISP Review, dated as completed on 8/19/21, was received on 2/15/23 and reviewed 3/8/23. DPOC by HDKP, HSLS, on 3/8/23]. |
10/03/2022
| Implemented |
| 6400.166(a)(11) | The September 2022 Medication Administration Record for Individual #1 indicates that the purpose for the dietary supplement Ensure Liquid Chocolate is weight gain; however, the instructions on the pharmacy label indicate drink 2 containers by mouth daily for weight loss. | 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 Program Specialist will review medication administration documentation practices with house staff to ensure they are aware of the need to ensure the prescribed medication label includes a diagnosis or purpose for the medication. If a purpose or diagnosis is missing or contradicts the label, staff will contact the prescribing physician and ask for documentation supporting why the medication is prescribed. [Documentation of monthly reviews of medication administration documentation for October 2022, November 2022, December 2022, and January 2023 were received on 2/14/23 and reviewed 3/8/23. Documentation of staff training, related to medication administration documentation, dated 2/7-8/23, was received on 2/13/23 and reviewed 3/8/23. DPOC by HDKP, HSLS, on 3/8/23]. |
10/28/2022
| Implemented |