| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.106 | Annual furnace inspection not found in record at inspection. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| The program Specialist will ensure that once the furnace reports are received. The furnace reports are stored in fire drill book for review. The program Specialist will so keep an electronic copy stored on the Box storage so that its readily available upon request. |
11/25/2022
| Implemented |
| 6400.217 | A copy of individual#1's signed release of information was not seen during the renewal inspection. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| In the even that there is another hybrid inspection and there are difficulties uploading documents as a result of problems with the agency scanner, the Program Specialist will scan a signed release of information when signature are updated annually. The document then will be stored in cloud (Box) to ensure they are available upon request. |
11/05/2022
| Implemented |
| 6400.34(b) | A copy of individual#1's signed individual rights was not seen during the renewal inspection. | 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. | In the event that there is another hybrid inspection and there are difficulties uploading documents as a result of problems with the agency 's scanner, the Program Specialist will scan an updated signed Indvidual rights documents of each participant during the time when an annual signature is updated. The document will then be stored in cloud (Box) to ensure they are available upon request. |
11/05/2022
| Implemented |
| 6400.165(g) | Individual #1 takes at least one psychotropic medication and their quarterly medication review conducted on 3/16/22 did not indicate if this medication should continue | 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. | The nurse will review the psychotropic medication quarterly review for completion by the end of the week of each review, if something needs to be adjusted or completed the nurse will summit the document to doctor for review . The nurse will remind staff during staff meetings to review the documentation for completion before leaving appointment. |
10/21/2022
| Implemented |
| 6400.182(c) | Individual#1's 2/18/22 assessment states that this individual self-medicates, however their 3/4/22 ISP states that they need a support person to prepare and administer their medications daily to maintain medication compliance. It also states that they need ongoing education around medication safety. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The program specialist will contact the supports coordinator in request that she updates the participant's ISP to reflect that the participant self-medicate. |
11/05/2022
| Implemented |