| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(b) | 5 large blank ants were observed in the main bathroom and approximately 7 to 10 large black ants were inside the individual's medication box hanging on the wall. | There may not be evidence of infestation of insects or rodents in the home. | An exterminator was hired to do a treatment on 03-01-2018. A monthly inspection will be done as well as preventative treatments. |
03/02/2018
| Implemented |
| 6400.67(a) | Peeling paint was observed on the ceiling above the shower in the main bathroom. The bathtub was observed to be in need of caulking, and the front panel on the bathtub was observed to be falling off. | Floors, walls, ceilings and other surfaces shall be in good repair. | Maintenance went in and painted, re-caulked, and fixed the panel on the tub. Monthly inspections will be done by maintenance to ensure this does not happen. |
03/04/2018
| Implemented |
| 6400.144 | On 09/08/2017 Lamictal dosage was increased to 150 mg by the physician. Change in dosage was not reflected on the medication administration record until 09/21/2017. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Medical Coordinator will ensure all services that are individualistic are documented and provided to every individual. Medical consult forms will help to assure all information is accurate. |
03/12/2018
| Implemented |
| 6400.163(c) | Individual's psychiatric medication reviews dated 09/08/2017, 10/09/2017, and 12/28/2017 did not include the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Sunset's Medical Coordinator and other team members will ensure all proper services are provided and treated by a physician who will review all medications and documentation every 3 months. |
03/10/2018
| Implemented |
| 6400.181(a) | Individual #1's assessment was completed on 01/30/2017 and not again until 02/23/2018. | 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 ensure each individual receives an assessment 1 year prior to or 60 calendar days after admission into the agency. An updated assessment annually will be kept which will include adaptive behavior and level of skills within 6 months prior to admission into the provider agency. |
03/14/2018
| Implemented |
| 6400.186(a) | Individual #1's ISP review for the period of 01/14/2017 to 04/13/2017 was not signed off as completed by the program specialist until 06/07/2017. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. | Sunset's Program Specialist will complete all ISP reviews of services and also expected outcomes in the ISP which is individualized in the community home every 3 months or more depending on needs of each individual. |
03/01/2018
| Implemented |
| 6400.186(d) | Individual #1's ISP reviews dated 01/24/2018, 10/13/2017, 07/31/2017, and 06/07/2017 were not sent to Individual's parents (i.e. was not sent to all plan team members). | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | Sunset's Program Specialist will provide an ISP review documentation or any recommendations to the individual's SC and plan team members within 30 calendar days. |
03/12/2018
| Implemented |
| 6400.186(e) | The notification of the option to decline the ISP review documentation was not provided to all team members (i.e. was not provided to the Individual's parents). | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | Sunset's Program Specialist will notify the individual's plan team members of the option to decline the ISP review documentation. |
03/08/2018
| Implemented |