| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(2) | The agency is the representative payee for Individual #1. The home did not keep an up to date financial and property record for Individual #1 to include: disbursements made to or for the individual. | (2) Disbursements made to or for the individual.
| The agency has developed the "Financial Management" policy and form which indicates the separate financial records for each individual, that includes the dates, amounts, deposits, withdrawals, reason for withdrawals, the financial source, expense records, and "refusal of receipts/ spending ledger" for individuals who refuse to let the agency record financial transactions and/or copy receipts. [Updated "Financial Management" policy received on 5/19/22 and reviewed on 5/20/22. "Receipt of Funds Acknowledgement" form received on 5/19/22 and reviewed on 5/20/22. Documentation of weekly review by Administrative Liaison received on 5/19/22 and reviewed on 5/20/22. DPOC by HDKP, HSLS, on 5/20/22]. |
04/22/2022
| Implemented |
| 6400.22(e)(1) | The agency is the representative payee for Individual #1.The home did not keep a separate record of financial resources, including the dates and amounts of deposits and withdrawals for Individual #1. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. | The agency has developed the "Financial Management" policy and form which indicates the separate financial records for each individual, that includes the dates, amounts, deposits, withdrawals, reason for withdrawals, the financial source, expense records, and "refusal of receipts/ spending ledger" for individuals who refuse to let the agency record financial transactions and/or copy receipts. [Updated "Financial Management" policy received on 5/19/22 and reviewed on 5/20/22. "Receipt of Funds Acknowledgement" form received on 5/19/22 and reviewed on 5/20/22. Documentation of weekly review by Administrative Liaison received on 5/19/22 and reviewed on 5/20/22. DPOC by HDKP, HSLS, on 5/20/22]. |
04/22/2022
| Implemented |
| 6400.22(e)(2) | The agency is the representative payee for Individual #1. The home did not keep a record of withdrawals for when Individual #1 is given the money directly , the record shall indicate the funds were given directly to the individual. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: For a withdrawal when the individual is given the money directly, the record shall indicate that funds were given directly to the individual. | The agency has developed the "Financial Management" policy and form which indicates the separate financial records for each individual, that includes the dates, amounts, deposits, withdrawals, reason for withdrawals, the financial source, expense records, and "refusal of receipts/ spending ledger" for individuals who refuse to let the agency record financial transactions and/or copy receipts. [Updated "Financial Management" policy received on 5/19/22 and reviewed on 5/20/22. "Receipt of Funds Acknowledgement" form received on 5/19/22 and reviewed on 5/20/22. Documentation of weekly review by Administrative Liaison received on 5/19/22 and reviewed on 5/20/22. DPOC by HDKP, HSLS, on 5/20/22]. |
04/22/2022
| Implemented |
| 6400.22(e)(3) | The agency is the representative payee for Individual #1. The home did not keep documentation, by actual receipt or expense record of each single purchase exceeding $15 made on behalf of Individual #1 carried out by or in conjunction with a staff person. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | The agency has developed the "Financial Management" policy and form which indicates the separate financial records for each individual, that includes the dates, amounts, deposits, withdrawals, reason for withdrawals, the financial source, expense records, and "refusal of receipts/ spending ledger" for individuals who refuse to let the agency record financial transactions and/or copy receipts. [Updated "Financial Management" policy received on 5/19/22 and reviewed on 5/20/22. "Receipt of Funds Acknowledgement" form received on 5/19/22 and reviewed on 5/20/22. Documentation of weekly review by Administrative Liaison received on 5/19/22 and reviewed on 5/20/22. DPOC by HDKP, HSLS, on 5/20/22]. |
04/22/2022
| Implemented |
| 6400.68(b) | On 3/2/22, at 11:02 AM, the water temperature was measured 143.4 Fahrenheit at the second-floor bathtub. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | On 3/2/22- The water temperature was adjusted to 118.7 degrees. The agency has added a "water temp check" section on the fire drill log.
This will ensure the water temperature is checked and recorded on a monthly basis. If it is found the temperature is beyond the 120 degrees regulatory requirement, staff will immediately adjust it to 118. degrees. [Copy of monthly fire drill form that includes a measurement of water temperature received on 5/19/22 and reviewed on 5/20/22. DPOC by HDKP, HSLS, on 5/20/22]. |
04/01/2021
| Implemented |
| 6400.165(g) | Individual #1 had a psychiatric medication review completed on 11/25/20 and then again on 5/19/21, exceeding the 90-day requirement. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | The agency CEO has sent several request (verbal phone conversation) to the psychiatric doctor to receive proof of med reviews for 2021 - in which the response was "they will eventually send them when they find them".
On another occasion, the medical office stated the records were at another office and they would get back to us.
As of April 20, 2022, the psychiatric office has not located or answered ALC's request.
The agency has developed an "information request form". The form includes the following:
1. Date of request
2. Staff making request
3. information requested
4. reason for request
5. who staff made contact with
6. Results of the request
***PLEASE NOTE: the individual from the dunbar site, and this site (both have the same psychiatric providers.*** ["Information Request Form" received on 5/19/22 and reviewed on 5/20/22. "Individual Data Tracking" system received 5/19/22 and reviewed 5/20/22. Weekly reviews by Administrative Liaison received 5/19/22 and reviewed 5/20/22. DPOC by HDKP, HSLS, on 5/20/22]. |
03/29/2021
| Implemented |