Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.82(f) | Th bathroom in the laundry room of the home did not have individual clean paper or cloth towels. [Repeat Violation, 8/8/2023] | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | The bathroom in the laundry room has paper towels. |
12/17/2023
| Implemented |
6400.113(a) | Individual #2, date of admission 7/23/2023, has not been instructed in general fire safety. [Repeat Violation, 8/4/2022] | 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. | Individual # 2 was instructed in Fire Safety upon admission. The Fire Safety Training was documented. |
11/15/2023
| Implemented |
6400.141(a) | Individual #1's most recent physical examination was completed on 12/7/2021. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #1's current Physical examination was placed in his binder. |
11/15/2023
| Implemented |
6400.141(c)(3) | Individual #2's physical examination, completed 1/25/2023, does not include immunizations. The physical examination states, "no immunizations recorded for this patient." | 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. | Individual's 2 Physical examination includes an immunization record. |
12/15/2023
| Implemented |
6400.141(c)(4) | Individual #1's most recent vision and hearing screenings were completed on 12/7/2021. [Repeat Violation, 8/4/2022] | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Individual's #1 most recent vision and hearing screenings are completed and stored in the individual's binder and their file. |
11/15/2023
| Implemented |
6400.141(c)(6) | Individual #1, date of admission 11/29/2022, has not completed Tuberculin skin testing. Individual #2 , date of admission 7/24/2023 had an initial Tuberculin skin testing completed on 7/28/2023. | 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. | Individual #1 completed a TB test prior to being admitted on 11/29/22. Individual #2 was placed in our agency for an emergency placement from Adult Protective Services therefore he was unable to get a TB test prior to being admitted. Individual #2 received a TB test when an appointment became available. |
11/09/2023
| Implemented |
6400.141(c)(12) | Individual #2's physical examination, completed 1/25/2023, does not include physical limitations of the individual. | The physical examination shall include: Physical limitations of the individual. | CEO contacted the physician to confirm if individual #2 has any physical limitations. |
12/07/2023
| Implemented |
6400.141(c)(14) | Individual #2's physical examination, completed 1/25/2023, does not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | CEO contacted the physician to confirm if individual #2 has any medical information pertinent to diagnosis and treatment. CEO asked Individual #2 who did he want contacted if their was an emergency. |
12/07/2023
| Implemented |
6400.142(a) | Individual #1, date of admission 11/29/2022, has not had a dental examination. [Repeat Violation, 8/4/2022] | 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. | Individual's # 1 dental examination was located in the binder and file. |
11/14/2023
| Implemented |
6400.142(f) | Individual #2, date of admission, 7/28/2023, does not have a dental hygiene plan. The individual's Individual Service Plan, last updated 11/08/2023, reads, "[Individual #2] requires minimal assistance to ensure he brushes his teeth daily." [Repeat Violation, 8/4/2022] | 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. | Individual #2 has a dental hygiene plan. |
12/07/2023
| Implemented |
6400.181(d) | Program Specialist #1 did not sign and date Individual #2's assessment, completed 9/11/2023. | The program specialist shall sign and date the assessment. | The Program Specialist signed and dated the assessment and placed the copied document in the individual's binder. |
11/14/2023
| Implemented |
6400.181(e)(1) | Individual #2's assessment, completed 9/11/2023, did not include the individual's functional strengths, needs and preferences. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | Individual #2's assessment included the individual's functional strengths, needs and preferences. The document was located in the individual's #2 binder. |
11/09/2023
| Implemented |
6400.181(e)(2) | Individual #2's assessment, completed 9/11/2023, did not include the individual's likes, dislikes and interests. | The assessment must include the following information: The likes, dislikes and interest of the individual. | Individual #2's assessment included the individual's likes and dislikes. The document was located in the individual's #2 binder. |
11/09/2023
| Implemented |
6400.181(e)(3)(i) | Individual #2's assessment, completed 9/11/2023, did not include the individual's current level of performance and progress in the acquisition of functional skills. | The assessment must include the following information: The individual's current level of performance and progress in the following areas: Acquisition of functional skills. | Individual #2's assessment included the individual's current level of performance and progress in the acquisition and functional skills. The document was located in the individual's #2 binder. |
11/09/2023
| Implemented |
6400.181(e)(3)(ii) | Individual #2's assessment, completed 9/11/2023, did not include the individual's current level of performance and progress in communication. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Communication. | Individual #2's assessment included the individual's current level of performance and progress in the following areas: Communication. The document was located in the individual's #2 binder. |
11/09/2023
| Implemented |
6400.181(e)(3)(iv) | Individual #2's assessment, completed 9/11/2023, did not include the individual's current level of performance and progress in personal needs with or without assistance from others. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal needs with or without assistance from others. | Individual #2's assessment included the individual's current level of performance and progress in the following areas: Personal needs with or without assistance from others. The document was located in the individual's #2 binder. |
11/09/2023
| Implemented |
6400.181(e)(9) | Individual #2's assessment, completed 9/11/2023, did not include documentation of the individual's disability, including functional and medical limitations. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | Individual #2's assessment included the individual's disability, including functional and medical limitations. The document was located in the individual's #2 binder. |
11/09/2023
| Implemented |
6400.181(e)(11) | Individual #2's assessment, completed 9/11/2023, did not include the individual's psychological evaluation. | The assessment must include the following information: Psychological evaluations, if applicable. | Individual #2 does not have an Psychological evaluation. He does not take any medication. |
11/09/2023
| Implemented |
6400.181(e)(13)(i) | Individual #2's assessment, completed 9/11/2023, did not include the individual's progress and current level in health. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| Individual #2's assessment included the individual's progress over the last 365 calendar days and current level in the following areas: Health. The document was located in the individual's #2 binder. |
11/09/2023
| Implemented |
6400.181(e)(13)(ii) | Individual #2's assessment, completed 9/11/2023, did not include the individual's progress and current level in motor and communication skills. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | Individual #2's assessment included the individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. The document was located in the individual's #2 binder. |
11/09/2023
| Implemented |
6400.181(e)(13)(iii) | Individual #2's assessment, completed 9/11/2023, did not include the individual's progress and current level in activities of residential living. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | Individual #2's assessment included the individual's progress over the last 365 calendar days and current level in the following areas: activities of residential living. The document was located in the individual's #2 binder. |
11/09/2023
| Implemented |
6400.181(e)(13)(iv) | Individual #2's assessment, completed 9/11/2023, did not include the individual's progress and current level in personal adjustment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | Individual #2's assessment included the individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. The document was located in the individual's #2 binder. |
11/09/2023
| Implemented |
6400.181(e)(13)(v) | Individual #2's assessment, completed 9/11/2023, did not include the individual's progress and current level in socialization. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | Individual #2's assessment included the individual's progress over the last 365 calendar days and current level in the following areas: Socialization. The document was located in the individual's #2 binder. |
11/09/2023
| Implemented |
6400.181(e)(13)(vi) | Individual #2's assessment, completed 9/11/2023, did not include the individual's progress and current level in recreation. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | Individual #2's assessment included the individual's progress over the last 365 calendar days and current level in the following areas: Recreation. The document was located in the individual's #2 binder. |
11/09/2023
| Implemented |
6400.181(e)(13)(vii) | Individual #2's assessment, completed 9/11/2023, did not include the individual's progress and current level in financial independence. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| Individual #2's assessment included the individual's progress over the last 365 calendar days and current level in the following areas: Financial independence. The document was located in the individual's #2 binder. |
11/09/2023
| Implemented |
6400.181(e)(13)(viii) | Individual #2's assessment, completed 9/11/2023, did not include the individual's progress and current level in managing personal property. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | Individual #2's assessment included the individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. The document was located in the individual's #2 binder. |
11/09/2023
| Implemented |
6400.181(e)(13)(ix) | Individual #2's assessment, completed 9/11/2023, did not include the individual's progress and current level in community-integration. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration. | Individual #2's assessment included the individual's progress over the last 365 calendar days and current level in the following areas: Community-integration. The document was located in the individual's #2 binder. |
11/09/2023
| Implemented |
6400.181(e)(14) | Individual #2's assessment, completed 9/11/2023, did not include the individual's progress and current level in knowledge of water safety and 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. | Individual #2's assessment included 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. The document was located in the individual's #2 binder. |
11/09/2023
| Implemented |
6400.34(a) | Individual #1, date of admission 11/29/2022, was not informed and explained individual rights. Individual #2, date of admission 7/24/2023, was not informed and explained individual rights. [Repeat Violation, 8/4/2022] | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Individual's #1 and Individual#2 were informed and explained of their individual rights upon admission. A copy of their Individual Rights and signature are in their binder. The original is located in their file. |
11/09/2023
| Implemented |
6400.46(a) | Program Specialist #1, date of hire 8/14/2023 does not have initial fire safety training. | Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Program Specialist completed initial fire safety. |
11/12/2023
| Implemented |
6400.46(c) | Program Specialist #1, date of hire 8/14/2023 does not have training in first aid techniques. | Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home shall be trained before working with individuals in first aid techniques. | Program Specialist, CPR training is recorded, available and current. |
11/09/2023
| Implemented |
6400.51(b)(1) | The orientation for Program Specialist #1, date of hire 8/14/2023 did not include the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Program Specialist completed Person Centered Practices. |
11/09/2023
| Implemented |
6400.51(b)(5) | The orientation for Program Specialist #1, date of hire 8/14/2023 did not include job related knowledge and skills. | The orientation must encompass the following areas: Job-related knowledge and skills. | Program Specialist completed job related knowledge and skills. |
11/09/2023
| Implemented |