| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | Individual #1's record does not include a property record/inventory list for personal items. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | It is important for individuals to have a property record/inventory list for personal items. It was discovered that individual #1s list was missing. It is the responsibility of the program specialist to ensure a property/inventory list is completed and maintained in each individual record. The program specialist will be retrained on this regulation by 6/30/2022. |
06/30/2022
| Implemented |
| 6400.67(a) | Light attached to the outside of the home near the front porch was not secured properly. | Floors, walls, ceilings and other surfaces shall be in good repair. | Upon licensing inspection it was found that a screw was loose in the light fixture outside of the residence. It is the responsibility of the CEO to maintain the home and to ensure all light fixtures are securely fastened. The CEO will be retrained on this regulation by 6/30/2022 and the light will be securely fastened into the cement within 90 days of this corrective action. |
09/01/2022
| Implemented |
| 6400.144 | Individual #1's physical dated 3/1/2022 includes special dietary instructions that recommend not to exceed 60oz of fluid a day. This doctor recommendation is not being followed as there is no record that staff are tracking the Individual's fluid intake. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| For the health and safety of all individuals it is imperative that special dietary instructions are followed. It was discovered at inspection that individual #1s fluid intake was not being measured. It is the responsibility of the medical coordinator to ensure that all dietary instructions from all physicians are being followed by Raphael House staff. The medical coordinator will be retrained on this regulation by 6/30/2022. It is important to note that individual #1s physician removed this recommendation. |
06/30/2022
| Implemented |
| 6400.50(a) | Orientation training documentation for Staff #1 does not include the length of training for the following trainings conducted on 3/19/21: Safe and Appropriate use of Behavior Supports, Implementation of the Individual Plan, the trainings conducted on 3/30/21: ODP Policies/Bulletins/Health Alerts, and trainings conducted on 4/1/21: Documentation & Raphael House's Daily Notes, QM, Everyday Lives. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | Prior to leaving our employ, Raphael House¿s former program specialist had all staff¿s training tied to her email in the form of google docs. Once she deleted her email we lost the hours of training for staff #1. It is the responsibility of the program specialist and program assistant to train and track training hours. They will both be retrained on this regulation by 6/30//2022 |
06/30/2022
| Implemented |