| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(a) | 05/2022 fire drill not held or provided at time of inspection. | An unannounced fire drill shall be held at least once a month. | Fire drill document for 5/2022 was found after the inspection and is uploaded into our EHR system on 12/19/2022. See attachment#14. |
12/19/2022
| Implemented |
| 6400.181(d) | Individual #1's assessment was not dated by the program specialist. | The program specialist shall sign and date the assessment. | Individual #1 assessment was amended to reflect date on 12/20/2022 in the EHR system to include the date the assessment was completed. See attachment#16. |
12/20/2022
| Implemented |
| 6400.181(e)(6) | Individual #1's assessment does not indicate safety around poisonous chemicals. | 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. | Individual #1 assessment has been amended/updated to reflect/explain the individual¿s ability to read and understand labels and safety around poisonous materials on 12/20/2022. See attachment#16, violation 3. |
12/20/2022
| Implemented |
| 6400.181(e)(14) | Individual #1's assessment does not indicate whether or not the individual can swim or needs supervision around water. Only indicates "she can regulate water temperature and she is safe around open bodies of water." | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | Individual #1 assessment has been amended/updated to reflect/explain the individual¿s current ability and knowledge of water safety and ability to swim on 12/20/2022. See attachment#16, violation 3. |
12/20/2022
| Implemented |
| 6400.165(g) | No psychotropic medication reviews were provided for individual #1. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Individual #1 psychotropic medication review documents (refill scripts) were retrieved from the doctor¿s office on 12/14/2022 referencing the dates for 1/11/2022, 5/31/2022, and 8/23/2022 that confirms completed appointments. See attachment#15. |
12/14/2022
| Implemented |