| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self-assessment form was not dated. | (a) 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.
| In the future, when the Program Director completes the self-assessment of each home, within 3 to 6 months prior to the expiration date of the certificate of compliance (April 1), the document will be dated and submitted to the Program Administrator for review. |
01/01/2015
| Implemented |
| 6400.64(a) | Mildew was found in the bathroom between the shower wall and the tub. | (a) Clean and sanitary conditions shall be maintained in the home.
| The old caulk and loose grout in the tub area, tub base and floor was replaced. |
03/19/2014
| Implemented |
| 6400.77(b) | The first aid kit lacked scissors and tweezers. | (b) A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served.
| The scissors and the tweezers were purchased and placed in the first aid kit. |
04/02/2014
| Implemented |
| 6400.186(a) | Individual # 1 was missing a quarterly from 9/13. | (a) The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP.
| The missing quarterly report was written, reviewed and signed by the individual. In the future, quarterly reports will be written every 90 days by the Program Specialist and reviewed by the Program Director. |
03/31/2014
| Implemented |
| 6400.213(1)(i) | The client record for Individual # 1 did not have a description or identifying marks for this individual. | Each individual's record must include the following information:
(1) 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.
| The individual's Emergency Medical Sheet (Face Sheet) for the individual's record was updated to include the required information. All individuals' records were updated to include the required information. |
03/31/2014
| Implemented |