| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(b) | Living room bay window broken, covered with plastic: says it is being reordered. Individual broke it. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Bay Window was repaired on 1/15/24. |
01/15/2024
| Implemented |
| 6400.72(a) | In the empty bedroom, a screen is missing on the window. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Window is broken and needs to be repaired. Upon repair screen will placed in window. A request has been placed with landlord to assess window and repair |
02/28/2024
| Implemented |
| 6400.81(k)(6) | There is no mirror in Individual 1's bedroom. | In bedrooms, each individual shall have the following: A mirror. | Maintenance Team placed a mirror in individual 1 bedroom. |
01/16/2024
| Implemented |
| 6400.111(a) | The attic does not have a fire extinguisher. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | Maintenance team installed a fire extinguisher in the attic. |
12/01/2023
| Implemented |
| 6400.141(c)(6) | Individual 1's TB testing was not received. | 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. | A prescription was requested on 1 24.23 for a TB test to be administered to individual . Upon receipt of prescription house manager and or staff will take him to get the TB test |
01/24/2024
| Implemented |
| 6400.141(c)(7) | Individual 1's GYN exam was due in November, the last exam was completed on 11/14/22. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Delay was caused by changing counties and insurance. Program Specialist applied for new insurance. Upon receipt of insurance card an appointment will be scheduled |
02/28/2024
| Implemented |
| 6400.181(e)(12) | The recommendations are not addressed in Individual 1's annual assessment for services, training, and programming. It references going out to play basketball and the YMCA. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Program Specialist revised assessment to include recommendations for specific areas of training, programming and services. |
01/01/2024
| Implemented |
| 6400.32(r) | Individual 1's individual rights form does not address that an individual has the right to lock their bedroom door. | An individual has the right to lock the individual's bedroom door. | Director of Operations amended individual Rights Policy was amended to include the right to lock their bedroom door. |
01/01/2024
| Implemented |
| 6400.166(b) | Staff Signed Individual 1's mar on 11/30 for metformin 500 mg for pm dosage in error. Medication was still in corresponding blister pack. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Staff were educated on appropriate storage and allocation of medication. Procedure implemented to assure staff are using respective and appropriate pack at the designated time when medication is given multiple times a day. |
12/01/2023
| Implemented |
| 6400.213(1)(i) | Individual 1's record does not list identifying marks. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Director fo Health Services amended face sheet for individual 1to include all identifying marks. |
01/24/2024
| Implemented |