| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Poisonous material (RAID), located in the lining closet was not locked or made inaccessible to individuals/children. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The (individual) was educated on the importance of keeping poisons looked up and away from children for their safety. Childproof locks were installed in the unit. Staff will review this annually with the individual. |
02/01/2021
| Implemented |
| 6400.68(b) | The hot water temperature in the home was tested during inspection and found to be 147. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Staff will complete and document weekly water temperature checks. See attachment #7. If the water temperature is above 120, it will be adjusted to a lower temperature. Hot water heater was adjusted at time of inspection to lower water temperature. The water temperature is now reading 106. |
12/21/2020
| Implemented |
| 6400.82(e) | The bathtub did not contain a nonslip surface or mat. | Bathtubs and showers shall have a nonslip surface or mat. | Individual was educated on the importance of keeping a non slip surface/mat in the bathtub for safety. Bath mat was purchased for the bathtub. |
01/22/2021
| Implemented |
| 6400.141(c)(14) | Individual #6's annual physical dated 8/11/2020 did not indicate information pertinent to diagnosis in case of emergency | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Nursing team and health care coordinator review documentation when it is entered into electronic record. nursing team/health care coordinator will contact physician for correction/clarification on documentation. The provider was contacted and the missing information was corrected. See Attachment #8. |
03/01/2021
| Implemented |
| 6400.142(a) | Individual #6's record indicates that a dental was scheduled for 11/27/2020, but that the provider canceled. There was no written documentation of this in the record. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Appointment was rescheduled made for 12/22/20. Individual refused appointment and it was rescheduled again for 2/2/21. Due to inclement weather on 2/2, this appointment was rescheduled to 2/12/21. |
03/01/2021
| Implemented |
| 6400.181(e)(7) | Individual #6's annual assessment dated 1/14/2020 does not indicate ability to understand heat sources. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | Assessments will be completed by the individual's program specialist. The assessment will then be reviewed by another program specialist who will proofread, advise if corrections should be made, and provide the feedback to the individual's program specialist. The individual's program specialist will then correct the assessment if needed and file the form. This assessment has been updated to reflect the individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. See attachment #9 |
02/01/2021
| Implemented |
| 6400.181(e)(7) | Individual #6's annual assessment dated 1/14/2020 does not touch on her ability to understand heat sources. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | Assessments will be completed by the individual's program specialist. The assessment will then be reviewed by another program specialist who will proofread, advise if corrections should be made, and provide the feedback to the individual's program specialist. The individual's program specialist will then correct the assessment if needed and file the form. This assessment has been updated to reflect the individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. See attachment #9 |
02/01/2021
| Implemented |
| 6400.181(e)(13)(i) | Individual #6's annual assessment dated 1/14/2020 does not report on progress and growth in several areas. The word "progress" appears but no further information. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| Assessments will be completed by the individual's program specialist. The assessment will then be reviewed by another program specialist who will proofread, advise if corrections should be made, and provide the feedback to the individual's program specialist. The individual's program specialist will then correct the assessment if needed and file the form. See attachment #9 |
02/01/2021
| Implemented |
| 6400.217 | At the time of inspection, there were no consents for release of information for individual #6 | 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.
| Program will complete an annual review of the consent packet to ensure all consents are present and up to date. The consent for release of information has been included in this individual's consent packet . See attachment #10 |
02/01/2021
| Implemented |
| 6400.183(b) | Individual #6's ISP dated 3/7/2020 did not include a sign in sheet for those who participated. | At least three members of the individual plan team, in addition to the individual and persons designated by the individual, shall be present at a meeting at which the individual plan is developed or revised. | A copy of the sign in sheet is normally made at the ISP; however there is no copier in this home. The SC did not send a copy of the sign in sheet. Going forward, program will request that two sign in sheets are completed at the meeting. The SC will keep one copy and the program will keep the other on file. A copy of the sign in sheet is now on file. See attachment #11 |
02/01/2021
| Implemented |
| 6400.186 | Individual #6's ISP dated 3/7/2020 listed ability to swim differently then the annual assessment for dated 1/14/2020. | The home shall implement the individual plan, including revisions. | Assessments will be completed by the individual's program specialist. The assessment will then be reviewed by another program specialist who will proofread, advise if corrections should be made, and provide the feedback to the individual's program specialist. The individual's program specialist will then correct the assessment if needed and file the form. See attachment #9 |
02/01/2021
| Implemented |