| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(b) | The fire drill on 8/1/16 did not list the staff present. | Fire drills shall be held during normal staffing conditions and not when additional staff persons are present. | This area of non-compliance was corrected on 1/28/17 by the Residential Director including the names of staff present during the fire drill on 8/1/16. This information was populated using the site schedule for the date for the date in question. In the future, the house manager will ensure that fire drills are held during normal staffing and that staff names appear on the fire drill. The Residential Director will assure the regulatory compliance. See attachment #9 |
01/28/2017
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination dated 5/2/16 did not list information pertinent to diagnosis in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | This was corrected on 1/28/17. In the future, the Community House Manager will check, document before filing to ensure that the information pertinent to diagnosis in case of an emergency is included in the Individual's physical form in accordance with the regulations. In addition, the Program Specialist will quarterly check, document and assure compliance. See attachment #8* |
01/28/2017
| Implemented |
| 6400.181(e)(13)(vi) | Individual #1's assessment dated 8/8/16 did not have progress and growth in the area of Recreation. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | This area of non-compliance was corrected on 3/23/17. The Program Specialist will ensure all assessments are written in accordance with 6400.181(13) (vi), and the assessment includes all required information including individual's progress and growth in area of recreation. The Residential Director will review and sign off all assessments to assure regulatory compliance. In addition during the annual Self -Assessment 15 (a), the Compliance Director will check to ensure compliance Corrected; with addendum assessment. See attachments #4, 5 & 6* |
03/23/2017
| Implemented |
| 6400.181(e)(13)(viii) | Individual #1's assessment dated 8/8/16 did not have progress and growth in the area of managing personal property. | 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. | This area of non-compliance was corrected on 3/23/17. The Program Specialist will ensure all assessments are written in accordance with 6400.181(13) (viii), and the assessment include all required information including individual's progress and growth in area of managing personal property. The Residential Director will review and sign off all assessments to assure regulatory compliance. In addition during the annual Self -Assessment 15 (a), the Compliance Director will check to ensure compliance. Corrected; with addendum assessment. See attachments #4, 5 & 7* |
03/23/2017
| Implemented |
| 6400.181(e)(13)(ix) | Individual #1's assessment dated 8/8/16 did not have progress and growth in the area of Community integration. | 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. | This area of non-compliance was corrected on 3/23/17. The Program Specialist will ensure all assessments are written in accordance with 6400.181(13) (ix), and the assessment includes all required information including individual's progress and growth in area of Community integration. The Residential Director will review and sign off all assessments to assure regulatory compliance. In addition during the annual Self -Assessment 15 (a), the Compliance Director will check to ensure compliance. Corrected; with addendum assessment. See attachments #4, 5 & 6* |
03/23/2017
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not document identifying marks. | Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. | Individual #1 record was corrected and dated by the Program Specialist on 2/19/17. In the future, the Program Specialist will make sure that the individual's record include the following information: The race, height, weight, color of eyes and identifying marks and assure regulatory compliance. In addition, the Program Director will review the individual record to assure the regulatory compliance. Corrected, see attachment #3 |
02/19/2017
| Implemented |