| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.65 | There was no mechanical ventilation located on the main level bathroom. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Binty Nurses, Inc. maintenance team schedule for the mechanical ventilation system to be repaired on 06/23/2023. |
06/23/2023
| Implemented |
| 6400.80(b) | The fence in the back yard was damaged, the metal wiring was detached from the posts. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | Binty Nurses, Inc. maintenance team repaired backyard fence on 6/13/2023. |
06/13/2023
| Implemented |
| 6400.181(e)(4) | The individual's initial assessment dated 7/15/22 did not discuss clearly the level of supervision needed in the program. The subsections in the assessment were not fully completed and clarified for levels needed in all areas. | The assessment must include the following information: The individual's need for supervision.
| Individual #1assessment has been updated to reflect the level of supervision needed in the program. All subsections in the assessment are fully completed and clarifies levels needed in all areas on 4/28/2023. |
04/28/2023
| Implemented |
| 6400.32(r) | The 3-bedroom doors in the home did not have the ability to be locked. Documentation from individual plan was not provided. | An individual has the right to lock the individual's bedroom door. | Binty Nurses, Inc. maintenance team will place locks on the bedroom doors, individual rights form will be signed by Individual #1 on 6/23/2023 |
06/23/2023
| Implemented |
| 6400.165(g) | There were no 90-day psychotropic medication reviews on file for individual#1 since 6/1/2022 admission. Individual is prescribed a psychotropic Reseperdone | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Individual #1, has had psychotropic medication reviews completed; 5/1/2023, 5/26/2023, 6/20/2023 by a license physician. All documentation has prescribing medication and continuing necessary dosages included. |
06/20/2023
| Implemented |
| 6400.181(f) | Assessment was not sent 30 days prior to the Individual plan meeting. The Assessment was sent to the team on July 15th, 2022, but the meeting was held on July 29th. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The Program Specialist was retrained on Assessment invites and plan lead documents sent to the team for initial meeting and annually thereafter on 4/28/2023. |
04/28/2023
| Implemented |