| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | A dresser located in Individual #1's bedroom was missing a knob. | Floors, walls, ceilings and other surfaces shall be in good repair. | The Dresser knob has been fixed. See Appendix C_VV |
03/16/2018
| Implemented |
| 6400.67(a) | A vent cover located on the ceiling in Individual #1's bedroom was rusted. | Floors, walls, ceilings and other surfaces shall be in good repair. | The Vvnt cover has been replaced. See Appendix D_VV. |
03/16/2018
| Implemented |
| 6400.112(f) | The front door was used as the exit for all fire drills held from November 2016 through May 2017. | Alternate exit routes shall be used during fire drills. | The managers have been retrained on the requirement to use additional exits during fire drills. See Appendix A |
03/16/2018
| Implemented |
| 6400.141(a) | The current annual physical examination for Individual #1 occurred on 5/10/2017 and the previous physical examination occurred on 1/07/2016. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Nursing has been retrained on regulatory requirements. See Appendix N |
03/16/2018
| Implemented |
| 6400.161(c) | Medications were stored in a mini refrigerator that was not locked and there was no separate locked container to hold the refrigerated medications. | Prescription and potentially toxic nonprescription medications stored in a refrigerator shall be kept in a separate locked container, unless it is documented in each individual's assessment that each individual in the home can safely use or avoid toxic materials. | This has been corrected. All medications stored ion the refrigerator are locked in locked bags. See Appendix E_VV |
03/16/2018
| Implemented |
| 6400.161(e) | The medication Clotrimazole, originally prescribed for Individual #1, had been discontinued but was still in the medication box. | Discontinued prescription medications shall be disposed of in a safe manner. | Managers retrained ion this issue. See Appendix A. Medication was removed from location. |
03/16/2018
| Implemented |
| 6400.181(a) | The current annual assessment for Individual #1 was completed on 10/26/2017; the previous assessment was completed on 7/29/2016. | 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. | Managers have been retrained on this requirement. See Appendix A |
03/16/2018
| Implemented |
| 6400.181(e)(13)(ii) | The current annual assessment completed on 10/26/17 for Individual #1 does not document progress and growth in the area of motor and communication. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | Assessment for individual #1 has been updated. Please see Appendix B_VV |
03/16/2018
| Implemented |
| 6400.181(e)(13)(vii) | The current annual assessment completed on 10/26/17 for Individual #1 does not document progress and growth in the area of financial independence.. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| Assessment for individual #1 has been updated. Please see Appendix B_VV |
03/16/2018
| Implemented |
| 6400.181(e)(13)(viii) | The current annual assessment completed on 10/26/17 for Individual #1 does not document progress and growth in the area of managing personal property. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | Assessment for individual #1 has been updated. Please see Appendix B_VV |
03/16/2018
| Implemented |
| 6400.181(f) | The current annual assessment completed on 10/26/17 for Individual #1 was not provided to the team at least thirty days prior to the ISP meeting which occurred on 11/10/2017/ | 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 manager has been retrained on this requirement. See Appendix A |
03/16/2018
| Implemented |