Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.67(a) | The hand railing and steps had peeling paint on the side egress of the home. | Floors, walls, ceilings and other surfaces shall be in good repair. | Maintenance contractor painted the steps at the individuals' home. Management will complete a weekly / monthly spot check to ensure that all maintenance issues are resolved in a timely manner. |
08/31/2018
| Implemented |
6400.141(c)(14) | Individual #1's physical dated 2/27/18 did not indicate information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Program Specialist will ensure that each section of an individuals physical is completed. |
08/31/2018
| Implemented |
6400.181(e)(12) | Individual #1's assessment dated 10/12/17 did not include recommendations for training. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Program Director will review assessment to ensure that the recommendations for training for each individual is completed. |
08/31/2018
| Implemented |
6400.181(e)(13)(i) | Individual #1's assessment dated 10/12/17 did not include current health status. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| Program Director will review assessment to ensure that individuals' assessment includes current health status'. |
08/31/2018
| Implemented |
6400.183(7)(iii) | Individual #1's ISP dated 1/11/18 did not include potential to advance in vocational programming. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following:Assessment of the individual's potential to advance in the following: Vocational programming. | Program Specialist will inform SC to update ISP in order to include the individuals' potential to advance in vocational programming. |
08/31/2018
| Implemented |
6400.183(7)(iv) | Individual #1's ISP dated 1/11/18 did not include the potential to advance in Competitive community-integrated employment. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Assessment of the individual's potential to advance in the following: Competitive community-integrated employment.
| Program Specialist will inform SC to update ISP in order to include the individuals' potential to advance in Competitive Community Integrated Employment. |
08/31/2018
| Implemented |
6400.186(c)(2) | Individual #1's ISP reviews dated 12/11/17, 3/11/18 di not report on community integration or behavioral plan. The ISP reviews dated 12/11/17, 3/11/18, and 6/11/18 did not include dental plan review. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | Program Director updated monthly / quarterly review form in order to ensure that all aspects of the individual's needs are addressed. |
08/31/2018
| Implemented |
6400.213(1)(i) | Individual #1's record did not include the religious affiliation. | Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.
| The field "Religious Affiliation" was added to the Residential Assessment in addition to it being in the Admission Packet in order to ensure that the field is consistently filled out. |
08/31/2018
| Implemented |
6400.213(11) | Individual #1's record is not consistent in recording diagnosis. The physical dated 2/27/18 identifies 4 diagnosis. The assessment and ISP identify 9. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | Program Director / Program Specialist will update the SC's in order for them to update the ISPs to what the residential provider has on file. Program Director / Program Specialist, in addition to updating the SC's, will update physical form and other forms with the individuals' diagnoses to ensure consistency. If there is a change, then the Program Director / Program Specialist will update the forms and the SC's. |
08/31/2018
| Implemented |