Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6500.17(a) | The self-assessment of the home was completed on 7/3/14; however, the certificate of compliance expired on 10/1/14. | If an agency is the legal entity for the family living home, the agency shall complete a self-assessment of each home the agency is licensed to operate within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter. | Self-assessment to be done 3 to 6 months before expiration of license. Self-inspections to be dated after April 1, 2015, and before July 1, 2015. Self-assessment form attached. |
02/14/2015
| Implemented |
6500.73 | The 6 outside basement steps did not have a handrail. | An interior stairway exceeding two steps that is accessible to individuals, ramp and outside steps exceeding two steps, shall have a well-secured handrail. | Ramp installed, photo attached. Safety checklist created attached. Family living provider to review on a monthly basis and information given to the family living specialist at which time all necessary repairs will be completed. Training given to family living provider and family living specialist. |
02/14/2015
| Implemented |
6500.121(c)(9) | The most recent prostate examinations for Individual #1 were completed on 7/11/13 and 11/13/14. | The physical examination shall include: A prostate examination for men 40 years of age or older. | Prostate examination scheduled. Form created to make sure that all medical appointments are completed within the annual time frame. Form attached. Family living specialist responsible for seeing that appointments are done within the time frame, and the program director will oversee this as well. Training given to family living provider and family living specialist. |
02/14/2015
| Implemented |
6500.133(c) | Medication reviews for Individual #1 were completed on 11/12/13, 2/20/14, and 8/7/14. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Form created to keep track of due dates for psychotropic medication reviews. Next review already scheduled (form attached). Family living specialist responsible for seeing that appointments are scheduled and completed. Program director to review this information as well. Training given to family living provider and family living specialist. |
02/14/2015
| Implemented |
6500.151(e)(1) | Individual #1's assessment, dated 10/4/14, did not include the functional strengths, needs and preferences of the individual. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | Functional strengths, needs, and preferences of the individual completed on the assessment. Family living specialist to review that the assessment was completed annually after signing off on the assessment. It will also be reviewed by the program director. Training given to family living provider and family living specialist. |
02/14/2015
| Implemented |
6500.151(e)(2) | Individual #1's assessment, dated 10/4/14, did not include the likes, dislikes and interests of the individual. | The assessment must include the following information: The likes, dislikes and interest of the individual. | The likes, dislikes, and interests of individuals #1 and #2 were completed on the assessment. Family living specialist approved the changes. Family living specialist will review the assessment annually to see that all information is completed and current. The program director will then also review the assessment. Training given to family living provider and family living specialist. |
02/14/2015
| Implemented |
6500.182(c)(1)(vi) | Individual #1's photograph was dated May, 2001. | Each individual's record must include the following information: Personal information, including: A current, dated photograph. | Current photo taken and dated. All photographs to be retaken within a 5-year period. The family living specialist will supervise that the time frame has been met and the program director will also see that the family living specialist has checked to see that photos are current. Training given to family living provider and family living specialist. |
02/14/2015
| Implemented |