| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The home's self-assessment, completed on 1/30/23, the agency certificate of compliance expires 8/27/2023. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| LIIs are scheduled to be completed beginning on the week of 3/20/23. Once completed, the LIIs will be turned into the Director of Compliance for review and to maintain. |
05/27/2023
| Implemented |
| 6400.80(a) | On 3/1/23 at 11:43 AM, a 9' by 3' patch of heavy moss, approximately 1.5" to 1" thick in several areas, was observed spanning across on the concrete patio outside of the sliding door from Individual #3's bedroom causing a slippery surface. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | The moss was removed on 3/20/23. All Supervisors were instructed to confirm that their sites outdoor areas are clear and in good repair by 3/24/23. |
03/20/2023
| Implemented |
| 6400.101 | On 3/1/23, the sliding glass door located off the kitchen was observed at 11:30 AM with an additional kick-lock at the bottom right corner of the door adjacent to the guiding track that is engaged by depressing the mechanism by foot. [Repeated Violation---3/29/22.] | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The kick lock was removed on 3/10/23. All Supervisors were instructed to confirm that there were no blocked egresses in their sites by 3/17/23. The Site Supervisors were instructed to confirm that all doors and exits are clear by 3/24/23. |
03/10/2023
| Implemented |
| 6400.104 | The home's Local Fire Department Notification Letter did not include the exact location of the individuals' bedrooms. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Letters to the local Fire Department were updated to include bedroom locations and mailed on 3/20/23. All supervisors were instructed to review their letters and confirm that they include the location of bedrooms and are accurate with the needs of the individuals no later than 3/17/23. |
03/20/2023
| Implemented |
| 6400.141(a) | Individual #1 had physical examinations completed on 2/26/21 and subsequently on 3/16/22. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | All Site Supervisors were instructed to report the last physical completion date to Res Management no later than 3/31/23. Res Management will maintain physical dates and confirm that physicals for 2023 are scheduled within annual time frames and monitor physical due dates. |
03/31/2023
| Implemented |
| 6400.142(g) | Individual #1's record included a dental hygiene plan completed on 10/27/22 but did not contain such a plan for 2021. Individual #1's 3/14/22 assessment indicates that they are not dental-hygiene independent. | A dental hygiene plan shall be rewritten at least annually. | All Site Supervisors were instructed to report the last dential completion date to Res Management no later than 3/24/23. Res Management will maintain physical dates and confirm that dental appointments for 2023 are scheduled within annual time frames and monitor due dates. |
03/24/2023
| Implemented |
| 6400.214(b) | On 3/1/23 at 11:05 AM, Individual #1's current three-month psychiatric medication reviews conducted by a licensed physician were not found at the home. Individual #1 is prescribed psychotropic medication. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| All Site Supervisors were instructed to report the last psychiatric completion date to Res Management no later than 3/31/23. Res Management will maintain physical dates and confirm that psychiatric appointments for 2023 are scheduled within annual time frames and monitor due dates. |
03/31/2023
| Implemented |
| 6400.18(i) | EIM Incident # 9148198 for Serious Illness has a discovery date of 1/7/23 with a final report due date of 2/6/23. No extensions have been requested, and no final report has been submitted. | The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension. | All open incidents that were near or over 30 days were reviewed and had an extension filed or were finalized on 3/17/23. On Monday mornings, the Director of Risk Management will provide a report of all open incidents to Residential Management. The incidents will be discussed every Friday morning with the Risk Dir and Residential Management. Quarterly, the Risk Manager will meet with the interagency Risk Management team to discuss incidents and trends. Documentation of all provided reports and meetings will be kept by the assisgned manager. |
03/17/2023
| Implemented |
| 6400.32(r) | Individual #2 signed form on 1/5/23 requesting a bedroom door lock. On 3/1/23 at 11:40 AM, Individual #2's bedroom door was observed with a privacy lock that can be opened with a common straight-edged object. | An individual has the right to lock the individual's bedroom door. | The individuals lock was replaced on 3/10/23. All Site Supervisors were instructed to review their individuals client rights packets no later than 3/24/23 and confirm the individuals who have requested a bedroom lock. Locks will be visually checked to ensure they allow adequate privacy. Requests to maintenance will be made for any inadequate locks by 3/31/23. |
03/10/2023
| Implemented |
| 6400.165(g) | Individual #1 is prescribed psychotropic medication. Their record includes three-month medication reviews by a licensed physician for the following dates: 9/27/22 and 1/30/23. | 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. | All Site Supervisors were instructed to report the last psychiatric completion date to Res Management no later than 3/31/23. Res Management will maintain physical dates and confirm that psychiatric appointments for 2023 are scheduled within annual time frames and monitor due dates. |
03/31/2023
| Implemented |
| 6400.181(f) | Individual #1's 3/14/22 assessment was sent to members of their individual plan team on 3/16/22. Individual #1's Individual Plan Annual Review Meeting was held on 4/13/22. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | An updated letter was created for the Program Specialists to provide to Supports Coordinators when mailing a functional assessment based on last years ISP date if an upcoming ISP has not been scheduled on 3/19/23. The letter will outline the need to schedule the ISP within required time frames. |
03/19/2023
| Implemented |