| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.101 | Obstructed exit- There was 4-5 inches of ice and snow out the kitchen door exit that is used during fire drills making it impossible to use in case of a fire | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Program Director will work with Maintenance department and staff to ensure all exits are clear of any ice/snow or any other materials that could block the exits on a daily basis. |
03/01/2019
| Implemented |
| 6400.141(c)(3) | Immunizations- Adults- Individual #1 annual physical exam dated 12/28/18 did not contain immunizations. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Medical Director and Assistant Medical Director will update the physical form for the individual to ensure all information is listed and correct. |
03/01/2019
| Implemented |
| 6400.141(c)(12) | Physical limitations- Individual #1's 12/28/18 did not list the physical limitations. The record indicated use of wheelchair and assistance that is needed daily. | The physical examination shall include: Physical limitations of the individual. | Assistant Director will conduct desk audits bi-weekly to ensure all paperwork is completed, signed and mailed/emailed to the appropriate persons in a timely manner. Medical Director will ensure that all information is listed on the physical form. |
03/01/2019
| Implemented |
| 6400.141(c)(13) | Allergies- Individual #1's 12/28/18 physical did not list all of the allergies. The physical only listed Zyrtec & Trileptal. The other allergies that Individual #1 has been diagnosed with are: Dogs, English Plantain, tree mixture, seasonal allergies, Silvadine, Toborox/Tobramycin. | The physical examination shall include: Allergies or contraindicated medications. | Assistant Director will conduct desk audits bi-weekly to ensure all paperwork is completed, signed and mailed/emailed to the appropriate persons in a timely manner. |
03/01/2019
| Implemented |
| 6400.144 | Health Services- Individual #1 is to go to PCP 1x a month for allergy injections. He was not taken in Nov 2018. There was no reason in the record as to why the appt was missed. This caused Individual #1 to have to adjust to a new dosage of the allergy injection. | 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 Director will ensure that appointment is made at the beginning of the month in case any situations would arise that Individual could not attend appointment then the appointment can be rescheduled immediately to ensure no appointments are missed. |
03/01/2019
| Implemented |
| 6400.181(e)(10) | Assessment- Life time medical history was not completed and sent with the assessment dated for 6/8/18 for Individual #1. | The assessment must include the following information: A lifetime medical history. | Assistant Director will conduct desk audits bi-weekly to ensure all paperwork is completed, signed and mailed/emailed to the appropriate persons in a timely manner. |
03/01/2019
| Implemented |
| 6400.181(e)(12) | Recommendations- This section was missing from the assessment dated 6/8/18 for Individual #1. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Assistant Director will conduct desk audits bi-weekly to ensure all paperwork is completed, signed and mailed/emailed to the appropriate persons in a timely manner. |
03/01/2019
| Implemented |
| 6400.181(f) | Assessment sent to all team members: There is no documented date when Individual #1's 6/8/18 assessment sent to all team members. | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| Assistant Director will conduct desk audits bi-weekly to ensure all paperwork is completed, signed and mailed/emailed to the appropriate persons in a timely manner. |
03/01/2019
| Implemented |
| 6400.186(b) | Individual sign & date ISP review- The ISP for time frame of April 6- July 5, 2018 was not signed or dated by Individual #1. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | Assistant Director will conduct desk audits bi-weekly to ensure all paperwork is completed, signed and mailed/emailed to the appropriate persons in a timely manner. |
03/01/2019
| Implemented |