| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | Walls and other surfaces throughout the common area and hallways were scuffed and damaged. There was an unpatched hole in the wall to the left of a main hall bathroom wall. Substantial marks and scuffing were on the walls of the stairwell leading to the basement. | Floors, walls, ceilings and other surfaces shall be in good repair. | A work order was placed with Maintenance on 3/19/2021, estimated completion date 4/8/2021. Attachment #1 |
05/31/2021
| Implemented |
| 6400.81(k)(5) | Individual#1's bedroom closet door was locked and inaccessible to the individual at the time of inspection. A waiver permission form was signed by the individual post inspection dated 2/9/2021 to ensure future compliance. | In bedrooms, each individual shall have the following: Closet or wardrobe space with clothing racks and shelves accessible to the individual. | Individual #1 has the key to the locked closet and can access the items any time. This information will be documented in the assessment. |
04/05/2021
| Implemented |
| 6400.141(c)(6) | Individual#3 Annual Physical (dated 07/15/2020) notes that his previous Mantoux Test was read on 07/25/2018. Documentation within the Individual Record shows that the next Mantoux Test was read on 02/06/2021. The period of time between the two tests exceeds 2 years and is therefore out of compliance. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Mantoux will be planted at the Annual Physical for all Woods' residents beginning in April 2021. |
04/30/2021
| Implemented |
| 6400.181(e)(6) | Individual#3 Individual Assessment (dated 11/09/2020) does not describe the individual's ability to safely use or avoid poisonous materials. The assessment states, "Due to the varying behavior and cognitive levels among Individual #3 and his peers, all cleaning products and potential poisons are locked in a closet and used only under supervision." This description does not make it clear whether the individual would be unsafe around poisons or the poisons are locked solely because the individual's peers would be unsafe around them. In addition, the description gives no insight into the individual's safety around poisons in other settings. | The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | Care coordinator will be trained to individualized needs for safety with poisonous material. |
04/30/2021
| Implemented |
| 6400.32(i) | Individual#2's closet and dresser were outside the individual's bedroom in a common area closet. The bedroom also did not contain, a mirror, dresser and bed foundation. The assessment and behavioral support plan did not adequately address the restriction and chosen location of personal belongings.
Documentation provided after inspection showed a current consent form from the individual's guardian allowing the modifications to the bedroom but no fade out or behavioral plan modification was provided. The Human Rights Team did not discuss the personal belongings restriction during 2020's logged minutes. | An individual has the right of access to and security of the individual's possessions. | The Director of Care Coordination will ensure that the Care Coordinator schedules the team meeting and the Residential Director will ensure that the Residential Manager does not restrict the use of an individual¿s personal property without requesting a meeting. |
05/31/2021
| Implemented |
| 6400.165(g) | Individual#3 is prescribed psychotropic medications. As such, the individual must see a Psychiatrist or Licensed Physician at least quarterly (every 3 months) for psychotropic medication review and management. Per the totality of the encounter forms in the Individual Record, the individual attended psychotropic medication reviews on 02/05/2020, 06/24/2020, and 01/23/2021. These appointments did not occur at least every 3 months as required. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | The appointments were missing due to COVID Pandemic. The current problems have already been corrected by the providers. He has been seen by his proscribing doctor on 1/23/2021 & 2/19/2021. |
02/19/2021
| Implemented |
| 6400.181(f) | There is no evidence within the Individual Record to indicate that individual#3's Annual Assessment (dated 11/09/2020) was sent to the members of the Individual Support Plan (ISP) Team at least 30 days prior to the ISP Annual Review Meeting, which occurred on 01/08/2021. There is such a letter in the Individual Record; however, it is dated 02/04/2021, which is outside of the required time frame. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Moving forward an Individuals Assessment will completed and mailed at least 30 days prior and documented in the record. RE training will occur to review this requirement. |
04/30/2021
| Implemented |
| 6400.213(1)(i) | Individua#3's record does not provide information on hair color, eye color, or the presence or absence of any identifying marks. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Hair and eye color were identified in the ISP on page 21, however moving forward the Care Coord will document hair, eye color and disgusting marks in the introduction section of the Resident assessment. Critical revision and retraining will occur |
04/30/2021
| Implemented |