Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.72(a) | The closet door in individual number one's bedroom is off the door jam and needs to be repaired. Also, the closet door in the office is jammed, unable to open and close, and needs to be repaired. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Closet door will be fixed. Optimal Lifestyle has a maintenance person that will be assigned to fix the issue with the door. |
10/28/2023
| Implemented |
6400.181(d) | The current assessment for individual number one was not signed or dated. | The program specialist shall sign and date the assessment. | Individual assessment was signed. |
09/28/2023
| Implemented |
6400.166(a)(9) | The medication administration record for individual number one incorrectly states that the prescribed Vitamin D-3 2000 dietary supplement should be taken 2 times per day. The prescription for Vitamin D-3 2000 units tablet states "take 1 tablet by mouth every day". | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | MAR was updated to reflect the change in frequency of administration for the Vitamin D3 supplement. |
09/28/2023
| Implemented |
6400.181(f) | The provider did not have records showing that the current assessment was sent to the Plan team. What was communicated was that the assessment was given to the team at the ISP meeting on 8/1/2023, therefore the assessment was not provided to the team 30 calendar days prior to the ISP meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Everyone on the individuals team has a copy of the most current assessment. A new SC was just assigned to the case and she was emailed a copy of it as well. |
09/28/2023
| Implemented |
6400.195(b) | The provider has a practice in place where the staff are required to lock the refrigerator and freezer in order to prevent individual number 1 from overeating. The provider's record shows that this individual has a history of excessive overeating and is taking medication (Tamomax) that is intended to decrease this overeating behavior, however this restriction is not covered in the behavior support plan. The behavior plan needs to be updated to reflect this practice and how to educate the individual on their condition. | The behavior support component of the individual plan shall be reviewed and revised as necessary by the human rights team, according to the time frame established by the team, not to exceed 6 months between reviews. | The behavior support plan was updated to reflect the restriction. A meeting will be scheduled with the members of the team including the legal guardian of the individual. |
10/28/2023
| Implemented |
6400.195(b) | Individual number one has a current behavior support plan that is being implemented by staff, however the plan has not been reviewed by the provider's human rights team within the past 6 months. | The behavior support component of the individual plan shall be reviewed and revised as necessary by the human rights team, according to the time frame established by the team, not to exceed 6 months between reviews. | The human rights team will schedule a meeting which will include the legal guardian of the individual. In this meeting we will discuss the behavioral support component and will do this quarterly. |
10/28/2023
| Implemented |