| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | Individual #3 is unable to manage his own finances according to his assessment dated 7/19/21 and his ISP. An up-to-date financial record is not being kept for him. | 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. | on 3/1/22 A money ledger was implemented to keep track of individual spending's and receipts. A financial policy has been implemented for staff to read, sign and follow it when caring for the individual. ( see attached money ledger, financial policy training emailed to Kristen) |
03/01/2022
| Implemented |
| 6400.64(a) | In the main bathroom, located in the medicine cabinet was an uncovered toothbrush with hair wrapped around the bristles of the toothbrush. Clean and sanitary conditions shall be maintained. | Clean and sanitary conditions shall be maintained in the home. | on 3/3/22. staff was re-trained on how to keep individual's hygiene product clean and neat. ( see attached training sign-in emailed to Kristen) |
03/03/2022
| Implemented |
| 6400.67(a) | In individual #4's bedroom window approximately 10 inches of what appeared to be gray weather seal was hanging down from her window. Surfaces shall be in good repair. | Floors, walls, ceilings and other surfaces shall be in good repair. | on 3/11/22. window was fixed by agency's maintenance person. ( see attached photo of fixed window emailed to Kristen) |
03/11/2022
| Implemented |
| 6400.110(a) | During the inspection, the attic did not have a smoke detector located in it. The pull down attic had a slide lock located on it, which the agency negated the need for a smoke detector. A smoke detector shall be on each floor including the attic. The agency provided the licensure with a photo of a smoke detector located in the attic in the afternoon on 2/24/22 after the inspection. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | On 2/24/22 A smoke detector was placed in the attic. And photo was sent to the licensure by the program specialist. on 2/24/22 |
02/24/2022
| Implemented |
| 6400.111(a) | During the inspection, the attic did not have a fire extinguisher located in it. The pull down attic had a slide lock located on it, which the agency negated the need for a fire extinguisher. Each floor shall have an operable fire extinguisher. The agency provided the licensure with a photo of a fire extinguisher located in the attic in the afternoon on 2/24/22 after the inspection. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | On 2/24/22 2-A fire extinguisher was placed in the attic by the program specialist and photo was sent to the Licensure that afternoon. |
02/24/2022
| Implemented |
| 6400.141(a) | Individual #3 had a physical exam on 7/30/20 and then not again until 9/8/21 or 8/30/21 as both dates were documented on the physical exam. This exceeds the annual requirement. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | on 3/3/22 Agency created a check list for the individuals indicating date of last physical and date when new physical will be due. ( see attached check list emailed to Kristen) |
03/03/2022
| Implemented |
| 6400.181(a) | Individual #3 was admitted on 4/30/21 and their initial assessment was dated 7/19/21. Their assessment was completed 80 calendar days after their admission date which exceeds the requirement. | 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. | on 3/1/22 Agency created a calendar with the individual and when their assessment are due. ( see attached Calendar emailed to Kristen) |
03/01/2022
| Implemented |
| 6400.181(e)(14) | Individual #3's assessment dated 4/30/21 didn't evaluate their ability 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. | on 3/10/22 Assessment corrected. Individual doesn't currently know how to swim. He is not safe in water. ( See attached corrected assessment emailed to Kristen) |
03/10/2022
| Implemented |
| 6400.165(g) | Individual #3 had psychiatric medication review on 11/4/21 and the form used did not include documentation on the reason for prescribing the medications. Individual #3 had psychiatric medication review on 5/7/21, and there was no documentation on the necessary dosage for the medications. | 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. | on 3/1/22 program Director wrote a letter to the Physician requesting that, he document the dosage, and reason for each medication prescribed and the need to continue. ( see attached letter to Physician emailed to Kristen). |
03/01/2022
| Implemented |