| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.81(k)(6) | No mirror in Individual 1's bedroom. | In bedrooms, each individual shall have the following: A mirror. | A mirror was placed in the individual¿s bedroom on 4/29/24. (Supporting Document S9) |
04/29/2024
| Implemented |
| 6400.82(f) | Basement bathroom not operational or in working order. The toilet does not function and its seat is damaged. The bathroom was found in an unclean and unhygienic state and there were no paper towels or toilet paper. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | This bathroom is not used by staff or individuals. The bathroom was locked and made inaccessible to all on 5/14/24 (Supporting Document S10). |
05/14/2024
| Implemented |
| 6400.110(a) | Smoke detector not in basement. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | The Smoke detector was moved from the top of the basement stairs to the basement on 5/14/24. |
05/14/2024
| Implemented |
| 6400.141(c)(1) | The most recent physical examination for Ind. 1 did not have a review of previous medical history. | The physical examination shall include: A review of previous medical history. | In the future the Residential Director will ensure the lifetime medical summary is sent with the physical form and will review individual¿s annual physicals upon completion to ensure the doctor reviews all necessary information and documents such |
05/01/2024
| Implemented |
| 6400.181(a) | Individual 1's assessment was done on 07/20/22 and was not updated until 11/15/23. | 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. | Residential Director was retrained on assessment timelines on 4/29/24. In the future Residential Director will ensure all assessments are completed annually. (Supporting Document S3) |
04/29/2024
| Implemented |
| 6400.34(a) | Individual 1 was last informed of their individual rights on 06/08/22. | 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. | The human rights form was updated on 5/29/24. All Individuals had their human rights forms updated by 6/10. |
05/01/2024
| Implemented |
| 6400.46(b) | Staff member 1, staff member 2, and staff member 3's fire safety training did not indicate who conducted the training. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Training was conducted by Our CEO/Fire Safety expert. In the future Residential Director will ensure all fire safety experts sign off on fire safety trainings and will become trained as an expert themselves. An additional addendum to the training has been created to ensure documentation of all required topics and home specific matters. All existing staff will review the new document by 7/25, and annually thereafter. All new hires will review the new document with their fire safety training. |
05/01/2024
| Implemented |
| 6400.46(d) | Staff member 1 and staff member 2 did not have CPR or first aid training in thier record. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Staff member 1 will complete CPR and FA training by 7/31. Staff member 2 is no longer employed with Special Friends. In the future Residential Director will keep a tracking sheet to ensure all new hires receive CPR/FA training and renewal within the required time frames. |
07/31/2024
| Implemented |
| 6400.165(g) | Individual 1 had a psychiatric medication review on 09/08/23 and next review was not done until 03/2024. | 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. | The doctor stated that he does not feel this individual needed to be seen more than every 6 months. The provider has since formally requested that the doctor see this individual every 90 days and they have agreed to do so In the future Residential Director will review all individual files to ensure all appointments are completed within the required time frame. For those individuals that see a psychiatrist, the provider has contacted each psychiatrist and requested that they review the individuals medications at least every 3 months. In the future, all Special Friends Individuals that are prescribe psychiatric medications will have their medications reviewed every 3 months |
05/01/2024
| Implemented |