| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.73(a) | The stairs exiting through the bilco doors in the basement did not have a hand railing. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | A handrailing will be added to the stairs exiting the bilco doors. |
11/01/2021
| Implemented |
| 6400.104 | Individual #4 moved into the home on 1/27/21. Notification was not sent to the fire department until 6/1/21, the notification sent to the fire department did not include correct information regarding the individual's level of need in assistance in evacuating. Individual's assessment and ISP indicate the individual requires full physical assistance to evacuate. The notification to the fire department states the individual is fully ambulatory and only requires verbal prompts to evacuate. Notification to the fire department shall be kept current. | 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.
| Regulation 6400.104 will be discussed at Futures Joint Meting which includes managers and program specialist. The requirement will be outlined for all parties. |
09/14/2021
| Implemented |
| 6400.34(a) | Individual #4 was not informed of their. right to manage finances and their right to voice concerns. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Futures has updated their individual rights to include the individual's right to manage their own finances. The updated individual rights will be reviewed with individual #4. Upon review the individual will sign an acknowledgement form. |
09/15/2021
| Implemented |
| 6400.52(c)(1) | Staff #4 did not receive training in the application of person centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Futures training committee will develop a list of trainings that meet the 6600 regulations for annual orientation and training. The list will be shared with program specialists, frontline supervisors, and direct support professionals |
10/15/2021
| Implemented |
| 6400.166(a)(11) | Individual #4's medication administration record did not include diagnosis or purpose for the following prescribed medications; Quetiapine fumarate 400mg, Quetiapine fumarate 200mg, Lamotrigine 200mg, L-Methylfolate 7.5 mg, Atomoxetine HCL 25mg, Buspirone HCL 30mg, Lamotrigine 150mg, Mirtazapine 15mg, Bisacodyl EC 5mg, Theremes-M, Levothroxine 112 mcg, Loratadine 10mg, Calcium 600-vit D3 400, 510 Polyethylene Glycol 3350, Alendronate Sodium 70mg, and Vicks VapoRub. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Frontline supervisor will add the diagnosis to the instruction for each medication of the MARs for October. Futures MAR template will be updated to prompt for a diagnosis for each medication. The updated MAR will be available by November 1, 2021. |
10/01/2021
| Implemented |