| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(c) | Coliform water tests were completed on 6/03/2022 and then again on 9/19/2022. This exceeds the 3-month requirement. | A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources¿ certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept. | CEO realigned administrative responsibilities and moved the Water Testing Procedure to the Residential Manger, as she is in the locations most often and works directly with the maintenance department(who does the water collection). |
01/11/2023
| Implemented |
| 6400.113(a) | Individual #1's most recent training in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home was completed on 8/06/2021. This exceeds the annual requirement. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | A Fire Safety Handout/review was developed, but unfortunately, individual #1 was severally ill, was going on Hospice and was not able to understand the information that was being presented.. he subsequently passed away on Feb 2. [Documentation of Basic Fire Safety Handout was received on 3/16/23 and reviewed 3/17/23. DPOC by HDKP, HSLS, on 3/22/23]. |
01/11/2023
| Implemented |
| 6400.181(a) | Individual #1's had an assessment completed on 10/15/2021, and then again on 12/22/2022. This exceeds the annual requirement. | 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, reviewed Programming regulations,(which included 6400.181(a)) to assure knowledge of required timelines. Signature/content was sent to HR Department. [Documentation of staff training related to initial and annual individual assessments, dated 1/30/23, was received on 3/16/23 and reviewed 3/17/23. DPOC by HDKP, HSLS, on 3/22/23]. |
01/30/2023
| Implemented |
| 6400.34(a) | Individual #1 was informed of and explained of the on 9/29/2021, and then again on 12/14/2022. This exceeds the annual requirement. | 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. | Provider/Program Specialist are now aware there are no exceptions to 6400.34(a) in regards to inviduals Rights, individual #1 was hospitalized at the time of his annual and did not have his rights reviewed with him during his admission at ACMH. [Documentation of the visual calendar for regulatory requirements 3/16/2023 and reviewed 3/17/23. DPOC by HDKP, HSLS, on 3/22/23]. |
01/16/2023
| Implemented |