| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The home's self-assessment, completed on 7/10/23, was not conducted either within 3-6 months of the current license's expiration date or within 6-9 months following the last annual inspection by the Department. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| The provider shall complete a self assessment with the completion date. |
08/21/2023
| Implemented |
| 6400.22(e)(1) | On 7/19/23, Individual #1's financial record was not up-to-date, as the ledger was found to be missing transactions, including funds received by and disbursements made to them for purchases. The agency provides assistance in maintaining Individual #1's finances, as their 2/21/23 assessment indicates the need for help in this skill domain. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. | The home financial documents shall have the dates deposits and withdrawls |
08/21/2023
| Implemented |
| 6400.62(a) | On 7/19/23, a container of Clorox wipes was found unlocked underneath the sink in the home's only bathroom at 10:05 AM. According to their 6/15/23 individual plan, Individual #1 is unsafe with poisonous substances. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Poisonous materials shall be kept locked or made inaccessible to individuals. |
08/21/2023
| Implemented |
| 6400.81(k)(6) | On 7/19/23, Individual #1's bedroom was observed without a mirror at 10:01 AM. This item is not restricted in their 6/15/23 individual plan. | In bedrooms, each individual shall have the following: A mirror. | Each individual shall have a mirror |
08/21/2023
| Implemented |
| 6400.101 | On 7/19/23, a blocked egress was observed in the attached garage at 10:10 AM. The door leading into the garage from the basement had a doorknob with a turn latch on the basement side and a flush lock on the garage side that could only be operated by inserting a straight edge object and rotating it. The garage does not have a man door and can only be exited through a vertical-opening automatic garage door that Individual #1 is unable to operate. [Repeated Violation---10/4/22, et al] | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Stairways halls doorways and exits from rooms and building shall be unobstructed |
08/21/2023
| Implemented |
| 6400.112(f) | According to the written fire drill record submitted from November 2022 to July 2023, the front door was used as the only evacuation route. This home includes additional exits. | Alternate exit routes shall be used during fire drills. | Alternate exit routes shall be used during fire drills. |
08/21/2023
| Implemented |
| 6400.113(a) | Individual #1 completed fire safety training 1/6/22, and then again on 1/25/23. [Repeated Violation---10/4/22, et al] | 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. | An individual shall be instructed on fire safety training upon initial admission and reinstructed annually. |
08/21/2023
| Implemented |
| 6400.141(c)(6) | Individual #1 had a tuberculin skin test via Mantoux method read with negative results on 11/25/20, and then again on 2/23/23. [Repeated Violation---10/4/22, et al] | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | The physical exam shall include tb skin test with neg results every 2 years or if positive and initial chest xray. |
08/21/2023
| Implemented |
| 6400.142(a) | Individual #1 had a dental examination completed on 2/15/22, and then again on 3/2/23. | 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. | Dental exam shall be completed annually |
08/21/2023
| Implemented |
| 6400.142(g) | Individual #1's record included a dental hygiene plan that was written on 2/15/22, and then re-written on 5/24/23. Individual #1 is not dental-hygiene independent according to their most recent assessment completed on 2/21/23. | A dental hygiene plan shall be rewritten at least annually. | A dental hygiene plan shall be rewritten at least annually |
08/21/2023
| Implemented |
| 6400.151(c)(1) | Direct Support Worker #2's date-of-hire is 6/25/22. Direct Support Worker #2's record did not contain any documentation that they had completed a physical examination. | The physical examination shall include: A general physical examination. | The physical exam shall include a general physical |
08/21/2023
| Implemented |
| 6400.15(b) | The agency used the Self-Inspection and Declaration Tool to measure and record compliance at the home on 7/10/23 instead of the Department's 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. | The agency shall use the dept of licensing inspection instrument of the community homes for individual with IDD |
08/21/2023
| Implemented |
| 6400.18(a)(3) | EIM Incident #: 9187427 involving a serious illness resulting in hospitalization was discovered on 3/21/23 and reported on 3/23/23. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Inpatient admission to a hospital.
| The home shall report the following incidents within 24 hours of discovery by a staff person. |
08/21/2023
| Implemented |
| 6400.18(i) | EIM Incident #: 9187427 involving a serious illness resulting in hospitalization was discovered on 3/21/23. Finalization of the incident was due on 4/20/23. The agency submitted a finalized report on 6/19/23. | The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension. | The eim must be finalized within 30 days of discovery of the incident by staff person |
08/21/2023
| Implemented |
| 6400.165(f) | Individual #1 is prescribed medication to treat symptoms of a diagnosed psychiatric illness. A written protocol to address their social, emotional, and environmental needs related to the symptoms of the psychiatric illness was not found as part of their individual plan or anywhere else in their record. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | Med is prescribed to treatment of diagnosed psych illness, there shall be a written protocol as part of the individual plan to address SEEP. |
08/21/2023
| Implemented |
| 6400.181(f) | Individual #1's most recent assessment was completed on 2/21/23 for an individual plan annual review meeting that had been already held on 2/20/23. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | THe program specialist shall provide assessment to the individual plan team at least 30 days prior to ISP meeting |
08/21/2023
| Implemented |
| 6400.207(4)(I) | On 7/19/23, Individual #1's prescribed pro re nata medication, Hydroxyz HCL Tab 50 MG---Take 1 tablet by mouth every six hours as needed for acute anxiety---was recorded on their July 2023 Medication Administration Record as having been given on the following days without documentation that COO #1 or COO #1's designee had been contacted: 7/1/23, 7/4/23, 7/5/23, 7/6/23, 7/9/23, 7/11/23, 7/14/23. Additionally, the administration instructions of Individual #1's prescribed pro re nata medication, Hydroxyz HCL Tab 50 MG, did not define the specific characteristics of what is meant by "acute anxiety," in order to determine if its administration is warranted, as Individual #1 is unable to request this medication. | A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition. | Chemical restraint shall have a treatment of symptoms of a specific mental emotional or behavioral condition |
08/21/2023
| Implemented |