Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.106 | Furnaces- The oil furnace was not cleaned annually. Individual #1 moved into the home 9/19/19. The home furnace has not been inspected or cleaned since 4/16/18. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| The furnace has been cleaned, it was cleaned on 2/17/2020, to ensure that it is not missed in the future the Administrative Assistant will monitor all inceptions and cleanings and will schedule future appointments. The next apportionment has been scheduled for 2/16/2021. Attached is the cleaning from the furnace on 2/17/2020. |
02/17/2020
| Implemented |
6400.141(a) | Physical exam- yearly- Individual #1 DOA was 9/19/19, the physical was not completed prior to admission. The physical was completed on 10/2019. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | It is the program specialist responsibility to ensure that all physicals are filled out and completed prior to admission and yearly after. This is to include all fields are filled out, and dated and signed, including the TB tests. The administrative assistant will review all physicals to ensure that they are complete and filled out on agency forms, and meet the deadline and criteria required. Attached is another individuals physical and admission date. |
02/20/2020
| Implemented |
6400.141(c)(6) | Physical exam- Mantoux TB was completed late 1/22/18 and not again until 2/6/20 for Individual #1. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | It is the program specialist responsibility to ensure that all physicals are filled out and completed prior to admission and yearly after. This is to include all fields are filled out, and dated and signed, including the TB tests every two years. The administrative assistant will review all physicals to ensure that they are complete and filled out on agency forms, and meet the deadline and criteria required.If there is a cancellation or change in a scheduled appointment, documentation will be added to the file. Attached is another individuals physical and admission date. |
02/20/2020
| Implemented |
6400.181(a) | Initial assessment- Individual #1's initial assessment was not completed within the 60 days of admission (9/19/19) The assessment was completed in December 2019. | 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. | The program specialist is responsible for completing all assessments with in the allotted time frame. The residential CEO is responsible for review all assessments/ reports to ensure they are complete, accurate and completed, reviewed and signed on the required time frame. Attached is a completed assessment that was completed within the 60 days of admission. |
02/20/2020
| Implemented |
6400.181(d) | Assessment- Individual #1's initial assessment was not signed and dated by the program specialist staff person #1. | The program specialist shall sign and date the assessment. | It is the residential CEO responsibility to check all assessments/report written by the program specialist to ensure accuracy and that all requirement are filled out, signed and completed. Another assessment is attached. |
03/20/2020
| Implemented |
6400.32(r) | Rights- Bedroom doors locked- Individual #1's bedroom door does not contain a locking mechanism for privacy. | An individual has the right to lock the individual's bedroom door. | The CEO and the House supervisor has spoken to each individual residing int the home. Due the the ability for some to use any form of locking system with their disabilities and also a concern from the individuals of the doors being locked, it is at each individual request that the doors remain as they are with no change to the locking system. This has been discussed with each individuals team and will be updated to reflect their wishes in each individual¿s ISP. |
02/18/2020
| Implemented |