| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.76(a) | There was a screw, approximately 3 inches long, protruding from the dining room chair leg that was bolted to the floor on the left side of the table. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Issue was corrected immediately by maintenance. |
03/08/2022
| Implemented |
| 6400.112(e) | The home at conducted a sleeping fire drill on 1/19/2021. The staff attempted to complete another sleeping drill several times in the month of May, but the individual refused. May was only 4 months from the last completed sleep drill. The agency could have attempted another sleep drill in both June and July in order to be in compliance with this regulation; however, another sleep drill was not attempted until September of 2021, which exceeds the 6-month requirement. | A fire drill shall be held during sleeping hours at least every 6 months. | Policies and procedures were updated: If an individual refuses a night fire drill, drills will continue weekly until the individual successfully completes a night fire drill. |
03/08/2022
| Implemented |
| 6400.141(c)(4) | Individual # 1 did not receive a hearing screening during most recent physical completed on 02/09/22. Hearing screenings are required annually. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Annual hearing exam was schedule for 02/25/2022 however was rescheduled for 4/27/2022 due to bad weather on 2/25/2022. |
03/08/2022
| Implemented |
| 6400.145(2) | Transportation to be used in case of an emergency is unclear. It states, "Staff will follow or meet emergency staff at my preferred hospital". | The home shall have a written emergency medical plan listing the following: The method of transportation to be used. | All individuals Emergency Medical plans were updated with person-specific information that includes the preferences of the individual (guardian) and how they will be transported to their preferred hospital in the event of an emergency. |
03/08/2022
| Implemented |
| 6400.145(3) | All of the homes had an emergency medical plan that did not specify what the staffing plan was in the event of an emergency. | The home shall have a written emergency medical plan listing the following: An emergency staffing plan. | All individuals Emergency Medical plans were updated with person-specific information that includes the preferences of the individual (guardian) and what the staffing ratios will be, additional staffing if needed, in the case of an emergency. |
03/02/2022
| Implemented |
| 6400.171 | There were glass bottles of sauce stored in the locked office that were opened and the instructions on the bottle state, "refrigerate after opening". If items need to be locked up for the safety of the individual, then a mini fridge should be purchased and put in the locked office so that the food can be stored properly. | Food shall be protected from contamination while being stored, prepared, transported and served.
| A mini-fridge was purchased and placed in the office. |
03/08/2022
| Implemented |
| 6400.182(a) | - Individual # 1's ISP plan last updated on 02/04/22 identifies a target date as November 26, 2020 for a less restrictive behavior support plan to be developed.
The ISP reads "A less restrictive behavior support plan can be developed if individual can refrain from displaying negative behaviors which may cause physical harm to self or others···Target date is November 26, 2020." Plan was not revised to reflect new target dates. | The program specialist shall coordinate the development of the individual plan, including revisions with the individual and the individual plan team. | Track changes were sent to the SC on 3/7/2022 to have Behavior Support section updated. |
03/08/2022
| Implemented |