| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(f) | The trash cans located outside of the home did not have lids. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | Director of Community Relations will replace trash cans that have lids that are attached to base of trash can |
12/31/2021
| Implemented |
| 6400.66 | The light located on the deck area in the rear of the home needs to be replaced or a new bulb may be needed. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Director of Community relations will replace light bulb with one that has higher watts |
12/30/2021
| Implemented |
| 6400.67(a) | The broken window blinds in individual 1's bedroom should be replaced. | Floors, walls, ceilings and other surfaces shall be in good repair. | Director of Community Relations will replace blind in room |
12/31/2021
| Implemented |
| 6400.110(e) | The smoke detectors in the home are not interconnected. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | Director of Community Relations will replace smoke detector to assure they are all interconnected |
12/31/2021
| Implemented |
| 6400.112(c) | There was no exit route listed for drill held on 11/29/2021 | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Executive Director will revise form to include all required information. House Manager will review fire drill forms to assure completed in its entirety. Will also review with staff how to appropriately complete fire drill log during staff meeting |
12/31/2021
| Implemented |
| 6400.112(e) | There were no sleep drills held over the past 6 months. | A fire drill shall be held during sleeping hours at least every 6 months. | Executive Director will revise Fire Log form to include time of fire drill. Will review form with House managers during team meeting. House Manager will provide two dates for sleep drills no later than March 30 |
12/31/2021
| Implemented |
| 6400.113(a) | There was no record of annual fire safety training completed for individual 2. | 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. | Program Specialist will complete Annual Fire Safety Training 30 days prior to the individual's initial arrival anniversary date |
12/31/2021
| Implemented |
| 6400.141(c)(3) | Immunization for DTAP was not current or up to date according to the documentation provided for individual 2. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Executive Director will revise physical examination form to align with ODP form |
12/31/2021
| Implemented |
| 6400.141(c)(6) | Verification of a TB test with negative results was not provided during review for individual 2. | 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. | Executive Director will revise physical examination form to align with ODP form |
12/31/2021
| Implemented |
| 6400.141(c)(11) | The physical for individual 2, dated 9/1/2021, did not discuss the assessment of health maintenances needs including but not limited to, medical regiment and bloodwork, | 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. | Executive Director will revise physical examination form to align with ODP form |
12/31/2021
| Implemented |
| 6400.141(c)(14) | The physical for individual 2, dated 9/1/2021, did not discuss information pertinent to diagnosis in case of emergency | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Executive Director will revise physical examination form to align with ODP form |
12/31/2021
| Implemented |
| 6400.142(f) | There was no annually updated dental hygiene plan found in the record for individual 2. | 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. | Director of Health Services will develop a Dental Hygiene planning form. The form will be reviewed with House Manager during team meeting |
03/30/2022
| Implemented |
| 6400.144 | Olopatadine Solution PRN was listed on the MAR ,but not present at the time of inspection for individual 2. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| House Manager will remove all discontinued medication. Director of health Services will update MAR to reflect only current medication |
12/31/2021
| Implemented |
| 6400.181(c) | The assessment dated 9/19/2021 for individual 2 did not indicate what it was based on. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | Executive Director will review and amend form to include a line to note purpose. |
12/31/2021
| Implemented |
| 6400.34(b) | Documentation that the individual rights were reviewed annually was not provided. The last documented statement was signed on 7/15/2020. More than one year has lapsed since acknowledgment of rights. | The home shall keep a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights. | Program Specialist will review annual rights no later than 30 days prior to initial intake anniversary date of individual |
12/31/2021
| Implemented |
| 6400.165(g) | Psychotropic medication reviews for medications such as sertraline and Trazodone prescribed to individual 2 were not completed every 90 days, most recent review provided for the calendar year 2021 was dated 5/20/2021. | 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. | House Manger will complete medication management form for in person and virtual appointments |
12/31/2021
| Implemented |
| 6400.194(d) | There was no documentation of individual 2's human rights team. A record of the human rights team meetings were not kept. The Agency used to develop the Restrictive plan did not provide meeting participation sign in sheets. | A record of the human rights team meetings shall be kept. | Executive Director will provide documentation of biannual Human Rights Committee meetings to be include at the CLA. |
12/31/2021
| Implemented |