| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The vents in the upstairs bathroom and both individual's bedrooms were covered in a significant layer of dust. | Clean and sanitary conditions shall be maintained in the home. | Staff were trained on the importance of maintaining a clean and sanitary home. al the vents were cleaned in the upstairs bathroom and all bathrooms were checked for cleanliness. |
05/30/2022
| Implemented |
| 6400.67(a) | Individual #4's bedroom wall had a hole in the wall at the base of the door.
The dryer door was broken, appeared to be bent and did not close properly. | Floors, walls, ceilings and other surfaces shall be in good repair. | Handyman was contacted and he is able to fix the base of the door and dryer, scheduled for 6/13/22 .Staff are retrained on the importance of and the process of reporting if flooring, walls and ceilings are in good repair. |
05/30/2022
| Implemented |
| 6400.101 | The door leading out of the home from the kitchen was secured with a dead bolt lock that required a key to open the lock from the inside of the home. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Handyman will update the locks on 6/8/22. staff, program coordinator, trained on the importance of ensuring that all stairways, halls, doorways are unobstructed. |
05/30/2022
| Implemented |
| 6400.106 | The furnace in the home is not inspected and cleaned annually. The most recent inspection and cleaning was completed on 3/18/21. | 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.
| Staff (program coordinator) were retrained on the importance of completing annual furnace inspection. furnace inspections were already scheduled for 2023 |
05/30/2022
| Implemented |
| 6400.110(a) | There was not an operable smoke detector in the basement of the home. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | the smoke detectors were onsite but did not have a battery. the detectors had batteries replaced and were reinstalled . A fire drill was completed and they were functioning fully. |
05/30/2022
| Implemented |
| 6400.110(b) | The smoke detector's outside of the individual bedrooms were more than 15 feet from the bedroom doors. | There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. | the smoke detector was reinstalled 15 feet from the bedroom. staff were retrained on fire safety and the importance of proper placement, per regulation of the smoke detector . |
05/30/2022
| Implemented |
| 6400.141(c)(11) | Individual #4's annual physical dated 9/8/21 did not include An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | individual physical did not include an assessment of the individuals health maintenance needs, medication regimen- the PCP was contacted and his physical updated .Staff were retrained on medical appointments process and all documentation required for annual physical and all parts that need to be completed in order to remain in compliance and get accurate information for the client's health. |
05/30/2022
| Implemented |
| 6400.141(c)(12) | Individual #4's annual physical did not include the physical limitations of the individual. | The physical examination shall include: Physical limitations of the individual. | individual physical did not include an assessment of the individuals' physical limitations the PCP was contacted and his physical updated. Staff were retrained on medical appointments process and all documentation required for annual physical and all parts that need to be completed in order to remain in compliance and get accurate information for the client's health. |
05/30/2022
| Implemented |
| 6400.141(c)(15) | Individual #4's annual physical dated 9/8/21 did not include special instructions for the individual's diet. | The physical examination shall include:Special instructions for the individual's diet. | individual physical did not include an assessment of the individuals' physical diet, the PCP was contacted and his physical updated. Staff were retrained on medical appointments process and all documentation required for annual physical and all parts that need to be completed in order to remain in compliance and get accurate information for the client's health. |
05/30/2022
| Implemented |
| 6400.142(f) | Individual #4 did not have a written dental hygiene plan. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | Individual # 4 dental hygiene plan was updated. Re-training was completed with the Program specialist and also the director to reaffirm the need for a dental hygiene plan for each of our individuals. |
05/30/2022
| Implemented |
| 6400.151(a) | Staff #2 has not had an annual physical completed since 8/29/18. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Staff#2 annual physical was updated and submitted. staff were retrained on due dates and mandatory compliance of annual physical and TB's. |
05/30/2022
| Implemented |
| 6400.15(b) | The self-assessment of the home was completed on 9/2/21. This assessment was not completed on the appropriate licensing inspection instrument. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | program coordinator was trained on the correct self-assessment that needed to be completed. |
05/30/2022
| Implemented |
| 6400.34(a) | Individual #4 was not informed of his individual rights. The last documented review of individual #4's individual rights was on 1/1/21. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Individual#4 rights was reviewed and updated. the program specialist was retrained on what is required yearly to be updated for clients. |
05/30/2022
| Implemented |
| 6400.52(c)(5) | Staff #2 did not receive annual training in the safe and appropriate use of behavior supports. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | Staff #2 received updated annual training regarding behavior support. |
05/30/2022
| Implemented |
| 6400.165(g) | Individual #1's review for psychiatric medications on 7/20/21 was late. The previous medication review was on 3/30/21. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | individuals#4 psych review has been updated and is currently in compliance. staff were retrained on the mandatory requirement of 90 day psyche reviews for individuals prescribed psychiatric medication |
05/30/2022
| Implemented |
| 6400.166(a)(11) | Individual #4's medication record did not list the diagnosis for the individual's medications. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Individual #4 medication record was updated to reflect current diagnosis. staff were trained on the expectations of what should be on MAR. |
05/30/2022
| Implemented |
| 6400.169(a) | Staff #2 did not receive annual training in medication administration. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | staff #2 received updated annual medication administration training and is currently in compliance . |
05/30/2022
| Implemented |