| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(b) | There was a hole in the kitchen floor in front of the refrigerator. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The hole in the floor will be repaired. |
03/30/2018
| Implemented |
| 6400.68(b) | The hot water temperature was measured at 123.8 degrees Fahrenheit. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Water temperature is checked monthly. Procedure will be reviewed with management on March 27, 2018 Employees will be instructed to inform management immediately if temperature exceeds 120 degrees. Managers will be expected to review by April 15, 2018 Maintenance will be contacted to adjust water temperature.
((maintenance adjusted water temperature 3/1/18 - CH 3/28/18)) |
03/27/2018
| Implemented |
| 6400.71 | The emergency telephone numbers posted in the home did not include the telephone numbers of the nearest hospital, local fire, police and ambulance numbers, or poison control. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| Emergency Telephone numbers located at the residence will be updated to include the nearest hospital, police department, fire department, ambulance and poison control center |
04/06/2018
| Implemented |
| 6400.181(a) | Individual #4's annual assessment dated 4/13/2017 was not complete because the progress and growth over the last 365 calendar days for the following areas: Health, motor/communication skills, activities of residential living, personal adjustment, socialization, recreation, and community integration. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | The Annual Skills Assessment has been revised to include progress and growth in all areas required by regulation. The revised Annual Skills Assessment will be reviewed with management on March 27, 2018 and will be implemented April 1, 2018. |
03/27/2018
| Implemented |
| 6400.181(e)(12) | The annual assessment dated 4/13/2017 for Individual #4 did not document recommendations for specific areas of training, programs and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The Annual Skills Assessment has been revised to include a section under skill areas that include recommendations for further programming, evaluation, training, services and/or outcomes.as required by regulation. The revised Annual Skills Assessment will be reviewed with management on March 27, 2018 and will be implemented April 1, 2018. |
03/27/2018
| Implemented |
| 6400.181(f) | The annual assessment dated 4/13/2017 for Individual #4 was not sent to the team at least 30 days prior to the annual ISP which was held on 4/20/2017. | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| The Annual Skills Assessment will be distributed to all team members at the Second ISP Review Meeting which is held no more than 90 days before the ISP Annual Review. Supports Coordination Unit has been informed that if the SC is not present at this meeting the Annual Skills Assessment will be emailed to the SC. This procedure will be reviewed with Program Specialist on March 7, 2018 and with management personnel on March 27, 2018. Email with this new procedure has been sent to Director of Supports Coordination on March 6, 2018 |
03/27/2018
| Implemented |