| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.43(b)(1) | The covid policy provided as it relates to visitors states that a visitor attestation questionnaire would be completed prior to visits to the home. Licensing was not given a questionnaire or screened prior to physical site inspections. CEO is responsible for the management and implementation of the agency's policy/procedures. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | Covid Policy will remain in place in all homes as required by Covid guideines and policy ,Vistor's will obtain required Covid policy prior to vistors coming to the site CEO will provide all vistors with asstestation questionaires, and program staff will be trained and provided with covid policy and procedures. |
09/08/2022
| Implemented |
| 6400.64(a) | Water would not drain out of the tub | Clean and sanitary conditions shall be maintained in the home. | Liquid drano was poured down the drained and maintenance cleared the drain. Provider staff will complete weekly checks. |
05/24/2022
| Implemented |
| 6400.113(a) | Documentation that Individual 4 was trained in Fire Safety was not provided at time of inspection. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | At the time of inspection the documentation to support training was at Aston Business Center date of training was 1/1/2022. Program specialist will will ensure all data for individual 4 is on site and all required logs. |
05/24/2022
| Implemented |
| 6400.141(a) | Individual 4 has not had a physical examination annually, last examination was dated and signed by physician on 05/07/2021. (Current physical not provided at time of inspection). | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Program specialist will maintain original and a copy at the actual residences as well as at Aston Business Center, |
05/24/2022
| Implemented |
| 6400.141(c)(10) | Physical Examination Form dated 05/07/2021 states Individual is not free of communicable diseases, as noted on physical form if this occurs there must be written specific precautions to ensure no spread of diseases. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | DSP Staff will confirm prior to leaving Dr. Office that every thing is completed |
05/24/2022
| Implemented |
| 6400.142(a) | An annual Dental examination performed by a licensed dentist for Individual 4 was not provided at time of inspection. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Provider at the time of inspection the documentation was prepared for submission via the hybrid portion of the licensing./ program specialist will ensure all denatl exams are current. program managers will attend appointments and provide follow-up |
05/24/2022
| Implemented |
| 6400.142(f) | There was no annual Dental plan provided during file review for individual 4. | 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. | program speclist will meet to come up with a plan to put into her isp to addresss. dental information will be collected by program specialist to be included in assessement and individual 4 program book |
09/09/2022
| Implemented |
| 6400.181(a) | An annual assessment for Individual 4 was not completed timely, agency provided an assessment dated 05/06/2022 it could not be determined if assessment was completed annually. (Individual 4 was admitted 03/01/2019, no assessment for 2020.) | 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. | program specialist will ensure individual assesments will remain on site and will maintain updates as required acording to regulations. Individual assesment will remain in program books as required program specilaist will submit docimentaion in a timely manner. AD will review records. |
05/24/2022
| Implemented |
| 6400.181(e)(5) | Individual 4 ability to Self-Administer medication was not documented on assessment dated 05/06/2022, it states to see attached assessment checklist (nothing provided). | The assessment must include the following information: The individual's ability to self-administer medications. | Program specialist will correct language, as Participant 4 does not to self medicate |
05/24/2022
| Implemented |
| 6400.181(e)(13)(i) | Individual 4 progress over the last 365 calendar days in (Health, Motor and communication skills, personal adjustment, recreation, financial and management of personal property) was not measured on the assessment form dated 05/06/2022. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| All documentation was included in assesment. and is reflective in program book. Program speclist and AD WILL ENSURE ALL DOCUMENTATION IS ACCURATE AND CURRENT. |
05/25/2022
| Implemented |
| 6400.181(e)(14) | The assessment dated 05/06/2022, does not indicate if Individual 4 knows how to swim. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | Individual 4 can not swim, individual will require a life jacket in all bodies of water (large or small) |
05/24/2022
| Implemented |
| 6400.217 | Written consents for Individual 4 were not provided at time of inspection. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| Program specialist will ensure that all required documentation is in program books and medical books on site and at main office. |
05/24/2022
| Implemented |
| 6400.31(b) | Signed copies of Individual Rights for Individual 4 were not provided at time of inspection. | The home shall educate, assist and provide the accommodation necessary for the individual to make choices and understand the individual's rights. | Documentation was provided for individual 4 , Program Specialist and managers will ensure all documents are presented to individual 4 as required by regulations. Signed copies are provided as required |
05/24/2022
| Implemented |
| 6400.165(b) | Individual 4 PRN-Acetaminophen 325mg tablet, take 1 tablet by mouth every 4 to 6 hours as needed for pain-blister pack was empty. None found in the home at inspection-prescriptions must be kept current. | A prescription order shall be kept current. | Individual 4 is NPO, receives all of her medication and feeding thru her "J" ENSURE ALL MEDICATION S ARE ON SITE MANAGERS AND DSP WILL CHECK MEDICATIONS |
05/24/2022
| Implemented |
| 6400.165(c) | Individual 4 10-Quetiapine Er 150mg-take 1 tablet by mouth at 8am daily and once a day at noon 12pm-12pm dosage administered before 12pm-it could not be determined when, as it was not documented on the mar.
Individual 4 Quetiapine Fumarate 250mg-take 1 tablet by mouth at 8pm daily-8pm dosage was missing from blister pack but not signed out on the mar. | A prescription medication shall be administered as prescribed. | Individual 4 is NPO, receives all of her medication and feeding thru her "J" ENSURE ALL MEDICATION S ARE ON SITE MANAGERS AND DSP WILL CHECK MEDICATIONS |
05/24/2022
| Implemented |
| 6400.166(a)(10) | Individual 4 Quetiapine Er 150mg-take 1 tablet by mouth at 8am daily and once a day at noon 12pm-12pm dosage administered before 12pm-it could not be determined when, as it was not documented on the mar. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | Medication was on site individual 4 is NPO, Medication will be checked by staff and pharmcy for accuracy as well as maintence of the (5) |
05/24/2022
| Implemented |