| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.106 | The furnace was inspection on 4/23/15 and again on 5/16/16 (24 days late). | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| Program Specialist, House Manager, and ID Director will assure that the furnace is inspected annually. If the local furnace inspector is unavailable to meet deadline then house manager will call other businesses and document all efforts to have the furnace inspected. The agency is moving towards have all CLA furnace inspections to be completed the same time each year to assist with compliance. |
10/30/2016
| Implemented |
| 6400.141(c)(14) | Individual 2's physical dated 4/1/16 does not contain information pertinent to diagnosis in case of an emergency, as this field was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Program Specialist and/or House Manager will obtain medical information pertinent to the diagnosis and treatment in case of emergency from primary care physician and place with physical in file by 11/1/16. Effective immediately staff attending annual physical will review form before leaving to assure completion. |
11/01/2016
| Implemented |
| 6400.142(a) | Individual 2 is 68 years of age. Individual 2's most recent dental exam was received on 5/21/14, and it was recommended by his dentist that he be seen annually. As of the date of this inspection, Individual 2 hasn't received a dental exam in over 2 years. | 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. | While receiving annual physical on 4/1/16 Individual's primary care physician conducted an oral screening exam. This was not included on his annual physical form however on 10/10/16 his physician issued a letter stating the oral cancer screening was completed. |
10/10/2016
| Implemented |
| 6400.181(d) | Individual 2's annual assessment completed on 10/24/2015 was unsigned by the program specialist. | The program specialist shall sign and date the assessment. | Annual assessment will be signed by 10/30/16. Effective immediately all annual assessments will be signed by program specialist. |
10/16/2016
| Implemented |
| 6400.186(b) | Individual 2's ISP reviews dated 9/24/15 and 3/17/2016 were not signed by the individual. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | ISP's from 9/24/15 and 3/17/16 will be reviewed with the individual and documentation will be added to the file to support the review. Effective immediately the individual's ISP will reviewed with him. If the individual is unable or unwilling to sign documentation will be made with the ISP. |
10/30/2016
| Implemented |
| 6400.213(1)(i) | Individual 2's record contains an undated photo of him. | Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. | An updated color photo with a date has been added to the individual's file and will be updated at minimum every 5 years. |
08/30/2016
| Implemented |