| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self-assessment for this home was completed on 12-23-2014; however, the agency's certificate expires on 3-19-2015. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, 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 assessments will be completed th 3-6 month timeframe. [CEO or designee will review self assessments for timeliness and accuracy for all agency homes. (AS 5/5/15)] |
02/27/2015
| Implemented |
| 6400.112(c) | The fire drill record did not address problems encountered for any of the fire drills. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Fire drill log revised to include problems encountered during the drills.[CEO or designee will training all staff who participate in fire drill of this addition to the form and what needs to be documented and who to report any problems encountered. (AS 5/28/15)] |
03/02/2015
| Implemented |
| 6400.163(c) | Individual #1's psychiatric review was completed on 11-19-2014, and the previous review was completed on 5-2-2014. | 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. | ALL 90 day reviews will be completred prior to due date. [CEO or designee will review all individual's records who are prescribed medication to treat symptoms of a psychiatric illness and develope a tracking system to record due dates for reviews and make appointments for the reviews so that the reviews are completed timely. CEO or designee will review the documentation to ensure all required information is present and will follow up accordingly. (AS 5/5/15)] |
02/27/2015
| Implemented |
| 6400.186(b) | Individual #1 did not sign the three-month reviews ending on the following dates: 11-14-14, 8-14-14, 5-14-14 and 2-14-14. Staff #1 did not sign the the three-month review ending on 5-14-14. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | Program Specialist and Individuals will sign all quarterly reviews. [CEO or designee will review the last 2 reviews for each Individual and the next 2 reviews for each Individual in all the agency homes to ensure the program specialist and Individual signed and dated the ISP review signature sheet upon review of the ISP. CEO or designee will continue to monitor a sample of 3 month reviews at least monthly for 1 year for the required signatures. (AS 5/5/15)] |
02/27/2015
| Implemented |