| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(g) | Sleep drills conducted on 4/28/22 and 10/25/21 were both documented as being completed at 11:00pm. Sleep drills shall be conducted at different times of the night and within timeframes defined under "Sleeping Hours" in the 6400-Regulatory Compliance Guide (RCG.) | Fire drills shall be held on different days of the week and at different times of the day and night. | Added to our Fire Drill & Systems Check form is a check box to ensure information is included on the document. Explanation following the "Time" is that the "time must vary from 11 previous fire drills." Program staff will take the previous 11 months drills into account when choosing drill time. |
12/01/2022
| Implemented |
| 6400.113(a) | Fire safety training for Individual #4 was completed on 6/9/21 and again on 8/15/22. This exceeds the annual time frame requirement. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | Fire Safety Training will be held no later than 4/15/2023 and every 6 months thereafter. Supervisors and Directors will be instructed to schedule and conduct fire safety training no later than 4/15/2023. Supervisors and Directors will be trained in this plan of correction. |
11/11/2022
| Implemented |
| 6400.142(e) | One dental report was submitted for review. Dental report for Individual #4 completed on 6/2/22 indicated that three-month cleanings should occur. There was no record of a follow up dental cleaning being completed as directed by 9/2/22. | Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed. | Program Supervisor will immediately schedule a follow-up dental appointment to address the issues documented in the previous dental appointment. |
11/11/2022
| Implemented |
| 6400.163(d) | At time of inspection all prescription medications were stored in a small, closed cabinet and secured with a child safety slide lock. The medications were not properly secured as this type of lock can be easily removed without a key or passcode. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | The Community Services Administrator (CSA) informed all supervisors on 11/3/2022 to "Please relocate all medications to a locked area of the program if they are not already locked up. This is a temporary plan of correction for licensing as we work on the permanent solution. The medications must be locked regardless of the individual's safeness around poisonous substances. |
12/01/2022
| Implemented |