| 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 Agencies 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 |
| 6400.104 | The home's Local Fire Department Notification Letter did not include the exact location of the individuals' bedroom. | 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(c)(7) | The most recent gynecological examination for Individual #1 was completed 1/28/2022. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | All Site Supervisors were instructed to report the last gynecological date to Res Management no later than 3/24/23. |
03/24/2023
| Implemented |
| 6400.32(r) | On 12/16/22, Individual #1 requested to have a door lock on their bedroom door. On 3/1/23, the doorknob was observed at 10:14 AM to have no locking mechanism. | 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 |