| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(7) | Individual #1, date of admission 7/2/22, had a gynecological examination completed 3/29/22 and then again 8/8/23. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Individual 1 will receive gyne exam annually on or before the date of last gyne exam. If the individual cannot be seen in a timely manner, documentation will be provided explaining why the exam could not be obtained in a timely manner. |
02/16/2024
| Implemented |
| 6400.181(a) | Individual #1, date of admission 7/2/22, had an assessment completed 6/13/23. There was not a previous assessment for Individual #1; therefore, compliance could not be measured. Individual #2, date of admission 7/7/22, had an assessment was completed 6/18/23. There was not a previous assessment for Individual #2; therefore, compliance could not be measured. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Program Specialist will establish a tracker and calendar alert for assessments. All new assessments will be completed at least 30 day prior to ISP meetings and within 1 year of the prior assessment. |
02/16/2024
| Implemented |
| 6400.34(a) | Individual #1 was informed and explained individual rights on 5/5/23 and 1/2/24 and Individual #2 was informed and explained individual rights on 5/5/23 and 1/2/24; however, the rights document did not include all of the individual rights as per 6400.32a through 6400.32v. Individual rights related to receiving scheduled and unscheduled visitors as per 6400.32(l) through individual rights related to negotiation of choices as per 6400.32(q), individual rights related to locking doors 6400.32(r)(1) through 6400.32(s)(3), individual rights related to access to food 6400.32(t) through r32(v) were not included. | 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. | Old rights paperwork has been shredded. New paperwork was generated and the house supervisor read the revised rights paperwork to each client 1/31/2024. All clients signed and dated acknowledgement of rights. A copy of the individual rights will be kept in their charts. All rights 6400.32a thru 6400.32v have been included in the revised paperwork. 6400.32l thru 6400.32q have been added to the new paperwork. 6400.32(r)(1) thru 6400.32(s)(3) and 6400.32(t) thru r32(v) were included in new paperwork. |
02/16/2024
| Implemented |
| 6400.166(a)(13) | Individual #1's 8:00AM medications Vitamin B-12 500mcg, Celexa 40 mg and Individual #1's 8:00AM & 6:00PM medication Advair HFA 230/21 AER were prepared and initialed as administered by Director #1, who stayed outside the home due to having Covid, but the medications were administered by House Manager #2 from 1/28/24 to 1/31/24. Individual #2's 8:00AM medications Adderall 20mg and Clonidine 0.1mg, Individual #2's 12:00PM medication Clonidine 0.1mg, Individual #2's 4:00PM medication Adderall 20mg, Individual #2's 5:00PM medications Clonidine 0.1mg, Singulair 10mg, and Trazodone 100mg, and Individual #2's 8:00PM medications Trazodone 100mg and Depakote ER 250mg were prepared and initialed as administered by Director #1, who stayed outside the home due to having Covid, but the medications were administered by House Manager #2 from 1/28/24 to 1/31/24. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | As many staff as possible will be trained on medication administration so that there is more than one person able to administer medication. Med trainer will continue to teach staff until they are able to pass the medication administration course. No person passing medication will be able to give medication drawn by another person. |
02/23/2024
| Implemented |
| 6400.181(f) | Program Specialist #6 provided Individual #2's assessment, completed 6/18/23, to the individual plan team members on 6/26/23 for the annual individual plan meeting that was held on 6/1/23. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Program Specialist has developed a tracker and a calendar alert for assessments. The program specialist will provide the assessment 30 prior to each individual plan meeting. Program specialist will provide assessment to individual plan team members within 30 days. |
02/16/2024
| Implemented |