| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.65 | There is no ventilation in the upstairs bathroom, the skylight is not operational. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| The CFO contacted Maintenance Service on 4/19/23 so that the chain to the skylight can be lowered to be in operable reach and satisfaction to licensing. Maintenance came out on 4/19/23 and ensured that the skylight vent was working correctly. |
04/19/2023
| Implemented |
| 6400.71 | The emergency telephone numbers were not listed on or near the telephone. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| On 4/24/23, The house manager printed out a new list of emergency numbers and had them laminated and taped down by the telephones. |
04/24/2023
| Implemented |
| 6400.141(c)(6) | Individual #1 does not have a current TB test. Per their 5/6/22, their most recent test is dated 12/4/20. | 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. | The Program Specialist scheduled individual #1 to be seen by his PCP on 5/12/23 to have his TB test updated to be in compliance with regulation requirements. In which this task was completed and a copy of individual #1 TB test was secured in his chart. |
05/12/2023
| Implemented |
| 6400.141(c)(14) | Individual #1's 5/6/22 physical does not include information pertinent to diagnosis in case of emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | A staff meeting and medication training were both conducted on May 10th in which all staff was informed that when escorting participants to any appointments, staff are to make sure that all forms are completed in its entirety with no lines left blank to prevent missing information such as the information pertinent to #1s diagnosis not documented on his physical. |
05/10/2023
| Implemented |
| 6400.181(a) | Individual #1 does not have a current program assessment on file. | 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 has a meeting/training scheduled for 5/25/23 to comprehend the required fields and information that goes into completing a program assessment needed for individual #1 chart. |
05/25/2023
| Implemented |
| 6400.165(b) | Individual #1's Medication CLINDAMYCIN PHOSGEL 1%, in med box not on individuals MAR. (Medication was discontinued) | A prescription order shall be kept current. | The CEO mandated all SCALP staff to attend medication training scheduled on 5/10/23, to minimize unwanted medication errors by participating in a refreshers course to prevent encounters such as #1¿s medication not being inside the box where it belongs and documenting properly as required by state regulations. |
05/10/2023
| Implemented |
| 6400.194(c) | There is not a record of who serves on the agency's human rights team on file with the agency. | The human rights team shall include a majority of persons who do not provide direct services to the individual. | A record of who serves on the agency¿s human rights team was created on 5/1/23 consisting of 4 people in total. These individuals have all agreed to come together for their first team meeting on 5/28/23. |
05/28/2023
| Implemented |