| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(e)(3) | On 11/15/23, Individual #1's financial ledger included the following handwritten receipts: $80.00 for "supplies for cleaning,"; $20.00 for "lunch" on 11/12/23. No actual, itemized receipts were provided verifying what was purchased for the above transactions that exceed $15. | 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. | On 12/13/2023 the individual was reimbursed $118.32 for the funds used to purchase the cleaning supplies. The agency representative that was responsible for the change was Terri Eggleton (supervisor). On 12/01/2023 the agency updated and signed a new room board contract along with the individual to reflect room and board being collect and not just room as we were previously taking. The agency representative that was responsible for the change was supervisor Terri Eggleton (supervisor). On 12/01/2023 the CEO updated the agency policy to reflect that when funds are being distributed directly to the individual hands that the person distributing the funds along with the individual will sign that the individual is %100 responsible for all funds placed their hands. In addition, all expenses over $15, in a case where the funds are not distributed directly to the individual's hands, there should always be an itemized receipt. The agency representative Joanne Walker will monitor the individual's funds quarterly to ensure prevention of misuse of funds and all guidelines are being met. On 12/1/2023 the CEO trained the agency representatives on the policy, implementation and guidelines of the updated room and board contract, and management of the individuals funds. |
12/01/2023
| Implemented |
| 6400.66 | On 11/15/23, the exit door leading from the dining room of the home was observed without an outside light or any sufficient lighting source nearby. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| On 11/20/2023 a light was placed outside of the door underneath the deck to provide lighting by the exit door landing. The light was placed by maintenance. The CEO was responsible for coordinating with maintenance team to install lighting in the appropriate location to ensure safety and compliance. The site supervisor is to monitor the function of the lighting monthly to ensure that it's functioning properly on supervisor checklist. On 11/20/2023 the CEO trained the Program Specliast along with supervisors on regulation that all rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. |
11/20/2023
| Implemented |
| 6400.112(c) | The written fire drill record provided from 12/12/22 to 10/8/23 is a three-page chart documenting all fire drills conducted. Near the bottom of each page is a field with two blank lines to document any problems encountered during the fire drill. However, any information provided in this field is not referenced specifically to any one fire drill. Therefore, compliance could not be measured to determine if all fire drills provided in the written fire drill record address problems encountered. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | On 11/21/2023 the agency representative (Administrator assistant) updated the Fire evacuation record/fire system check sheet to reflect problems during fire drill being kept and tracked every time a fire drill is being performed. The new procedures will be implemented on upcoming fire drill and every fire drill thereafter. The site supervisors will check each fire drill log to ensure compliance is being met, tracking will be completed on lead checklist to prevent the violation from occurring again. This tracking system will apply to every fire drilled performed. On 11/21/2023 CEO trained Program Specialist and supervisors on updated Fire Evacuation Record. |
11/21/2023
| Implemented |
| 6400.24 | On 11/15/23, Individual #1's financial ledger included the following handwritten receipts: $80.00 for "supplies for cleaning, Chapter 6100.684(d)IV requires that cleaning supplies be provided with room and board. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | On 12/01/2023 the individual was reimbursed $118.32 for the funds used to purchase the cleaning supplies. The agency representative that was responsible for the change was Terri Eggleton (supervisor). On 12/01/2023 the agency updated and signed a new room board contract along with the individual to reflect room and board being collected and not just room (Room was the only collected in the previous months. The agency representative that was responsible for the change was supervisor Terri Eggleton (supervisor). The agency representative Joanne Walker will monitor the individual's funds quarterly to ensure prevention of misuse of funds and all guidelines are being met. On 12/1/2023 the CEO trained the agency representatives on the policy, implementation and guidelines of the updated room and board contract, and management of the individuals funds. |
12/01/2023
| Implemented |
| 6400.32(n) | On 3/29/23 a form entitled, "House Phone Agreement for [Individual #1]" was signed by Individual #1, their behavior specialist, and agency staff. This agreement restricts Individual #1's telephone usages times and does not permit them to have private conversations. Individual and staff interviews conducted on 11/15/23 during the on-site Renewal Inspection revealed also that Individual #1's telephone usage is being restricted. Individual #1 does not have a restrictive procedure plan. | An individual has the right to unrestricted and private access to telecommunications. | On 11/16/2023 the agency voided house agreement and informed Behavior Support team that we will no longer be using phone plans to prevent this violation from occurring again. On 11/16/2023 the agency notified staff along with the individual that the phone agreement is void and will no longer be used. On 11/20/2023 trained Program Specialist on what's considered restrictive and the guidelines for restrictive interventions and when they can and should be used. |
11/16/2023
| Implemented |