| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The floor and the wall in the kitchen was sticky and discolored. The radiators in the apartment were rusty and in need of repairs due to them not being on corectly. | Clean and sanitary conditions shall be maintained in the home. | Correction: Wall was thoroughly cleaned 2/24/17 and painted. , Baseboards were repaired or replaced.
Person Responsible: ATC will do monthly physical site inspection to ensure compliance with regulation 6400.64(a)
See attachment #17 JDB Service Group Inc. Closed Job # 1, #3, #8, #9 |
03/30/2017
| Implemented |
| 6400.67(a) | The dresser in individual #1 and individual #2's bedroom were missing knobs. The walls in the living room were patched but not painted. The light fixture in the dining room was missing a section of glass. The door in individual #1's bedroom was hitting the thermostat on the wall casuing it to break. | Floors, walls, ceilings and other surfaces shall be in good repair. | Correction: Knobs were installed on 2/14/17
Person responsible: ATC will complete monthly site inspection to ensure continued compliance with regulation 6400.67(a)
See Attachment #17- JDB Service Group Inc. Job Closed #2, #4, #5 |
03/07/2017
| Implemented |
| 6400.67(b) | There were splintering pieces of wood connected to the bottom of individual #1's bed whcih were consistent with an old headboard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Correction: Wood was removed 2/14/17.
Person Responsible: ATC will complete monthly site inspection to ensure compliance with 6400.67(b)
See attachment #17 JDB Service Group Inc. Closed Job # 7 |
03/30/2017
| Implemented |
| 6400.181(c) | Individual #1's annual assessment dated 9/11/16 did not indicate what the assessment was based on. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | Correction: Individual #1 assessment was updated.
New template was implemented and PS were trained on implementation 2/15/17
Person Responsible; Program Specialist
See attachment: #16 Individual #1 Summary of Assessment |
02/15/2017
| Implemented |
| 6400.213(1)(i) | Individual #1's record did contain a photograph, but it was not dated and it was very poor quality. | Each individual's record must include the following information: 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. | Correction: Individual's photograph was updated 2/1/17 and added to file and electronic record. The case record review has been revised and includes photograph within 5 years.
Person Responsible: Program Specialist are responsible to have current clear photograph of each resident in the individual's record and electronic file.
See attachment #15- photograph of individual #1.
Program Specialist were retrained 2/15/17 |
03/30/2017
| Implemented |