| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | Self-assessment of the home was not completed 3 to 6 months before the expiration of the license. | 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.
| A self-assessment was properly completed on 9/27/16. In the future the Assistant Executive will be responsible for properly completing all self-assessment 3 to 6 months before the expiration of the license. |
09/27/2016
| Implemented |
| 6400.62(a) | Lander mouthwash and Febreeze were found unlocjed under the hallway bathroom sink. Cerama cooktop cleaner which indicates to contact poison control if ingested was found unlocked under the kitchen sink. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The locks were repaired the same day while the Inspector was there. The supervisor do daily house checks to make sure that the physical site is compliant with the 6400 regulations. Any non-compliance is reported to the Maintenance department who makes repairs within 48hrs. |
03/16/2016
| Implemented |
| 6400.64(e) | There was no lid on the trashcan located in the kitchen. | Trash receptacles over 18 inches high shall have lids. | A new trashcan was purchased on 3/21/16. At the time of inspection the site did not have a Program Supervisor. The site now have a Supervisor who is responsible for making sure that the house is compliant with 6400 regulations. |
03/21/2016
| Implemented |
| 6400.68(b) | The water temperature in the bathroom was 147.3 degrees. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | A regulator was placed on the heater at the site that stops the water temperature from going higher than 120 degrees. The Program Directors are also checking the water temperature at the site weekly to make sure that the temperature is compliant with regulations specifications. |
05/16/2016
| Implemented |
| 6400.112(a) | Staff are aware of fire drill's through a fire drill schedule maintained in a binder. | An unannounced fire drill shall be held at least once a month. | Schedule for monthly fire drills was removed from the homes. The program directors for the houses now do unannounced fire drill. The arrived at the house and conduct the fire drills themselves or they call the monitoring company and set up the time for the fire drills then they call the house and instruct the lead staff to set off the fire alarm and conduct the fire drill. The Program Director stays on the telephone until the drill is completed to make sure that it is done in the time allotted. |
03/17/2016
| Implemented |
| 6400.141(c)(4) | Individual #1 physical dated 7/15/15 indicated further evaluation recommended by a specialist for vision and it did not occur.. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Individual #1 started residing with Royer Greaves School for blind in October 2015. She is legally blind due to optic nerve hypoplasia which was diagnosed by Wills Eye when she was three months old. Individual #1 has an appointment with her Ophthalmologist on 1/5/17. |
01/05/2017
| Implemented |
| 6400.161(a) | The medication "Patady" was stored in the medication box for "Lotemay" and Lotemay was stored in the box labeled "Patady". | Prescription and nonprescription medications shall be kept in their original containers, except for medications of individuals who self-administer medications and keep the medications in personal daily or weekly dispensing containers. | The error was corrected at the time of the inspection, while the Inspector was still at the home. The staff person that made the error was given a med practicum on 3/22/16 to ensure that she was following the proper steps for administering medication safely. On 4/8/16 at the monthly staff meeting a training was held for all staff about the importance of following the proper procedure for giving medication and the repercussions to the Individuals that live at the house if the proper steps are not followed every time medication is administered. |
03/08/2016
| Implemented |
| 6400.181(c) | Individual # 1 assessment dated 10/24/15 did not document the basis of the assessment. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | A new assessment was completed on September 23, 2016 documenting the basis of the assessment. In the future the Program Specialist will complete all assessments making sure that the basis of the assessment is clearly stated. The Assistant Director will review all Assessments before they as sent out to the team making sure that it completed accurately. |
09/23/2016
| Implemented |
| 6400.186(d) | Individual # 1's 3 month review documentation dated 1/6/16 was not sent to the SC or team members. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | Copy of the 3 month review was given to the SC on March 22. Copy of 3 month review was mailed to Individual #1's mother on March 17th. In the future to make sure that this error does not occur again the Program Specialist will be responsible for making sure that all 3 months reviews are sent out to the team. |
03/22/2016
| Implemented |
| 6400.217 | Individual #1 record did not include a consent for release of information. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| A release of information consent has been sent to individual #1 mother for approval. In the future the Program Specialist will review all Individual's files and make sure that all Consents are present and up to date. |
12/21/2016
| Implemented |