| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(e)(3) | Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. As per Individual #1's Individual Support Plan (ISP) they need assistance managing money as they are still learning skills for managing money. There was no receipt for 3/2/23 purchase at Speedway for $20.00, 1/17/23 purchase of $20.00, and a 12/1/22 Dominio's Pizza purchase for $23.00. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | The agency had kept the majority of receipts with these few missing the expense record did note the nature of the expense due to exceeding $15.00. We will keep all receipts over $15.00 moving forward. |
03/20/2023
| Implemented |
| 6400.101 | Stairways, halls, doorways and exits from rooms and from the building shall be unobstructed. The door in the basement leading to steps to the bilco door which lead outside would only open approximately ¼ of the way open as a white hutch was blocking the door from opening. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The unit was moved aside so as not to obstruct the egress. |
03/20/2023
| Implemented |
| 6400.110(a) | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement. At the time of the inspection, the basement did not have a smoke detector located in it. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | The agency installed a smoke detector in the basement. ( Please see image sent via email) |
03/20/2023
| Implemented |
| 6400.112(e) | A fire drill shall be held during sleeping hours at least every 6 months. There is no documentation of a fire drill occurring during sleeping hours from 4/2022 through 2/2023. | A fire drill shall be held during sleeping hours at least every 6 months. | The agency ran an asleep fire drill to come into compliance to date for safety, although the prescribed timeline had been exceeded. (Please see the image sent via email) |
03/20/2023
| Implemented |
| 6400.141(a) | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Individual #1 had a physical examination on 5/5/21 physical examination and their next one occurred on 8/11/22. This exceeds the requirement. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The agency has been working with his mother who takes him to his medical appointments per her choice. We have educated her as to the need to adhere to the regulatory timelines moving forward. |
03/20/2023
| Implemented |
| 6400.141(c)(3) | Individual #1s physical examination dated 8/11/22 did not include Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service. | 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. | The additional documentation provided by the physician was not included in the agency form. (Please see image sent via email) |
03/20/2023
| Implemented |
| 6400.141(c)(4) | Individual #1's physical examination dated 8/11/22 did not include a vision and hearing screening. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | The additional information has been emailed for ODP review. The Residential Director is working with the mother to ensure each area of the agency form is completed by the medical provider. |
03/20/2023
| Implemented |
| 6400.141(c)(11) | Individual #2's physical examination dated 8/11/22 did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals as this section of the physical examination was left blank. | 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. | The additional information has been emailed for ODP review. The Residential Director is working with the mother to ensure each area of the agency form is completed by the medical provider. |
03/20/2023
| Implemented |
| 6400.181(e)(9) | Individual #1's assessment dated 3/12/22 did not include documentation of the individual's disability, including functional and medical limitations as this section of the assessment was left blank. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | The information was carried over from the Lifetime Medical History document for full compliance with the regulation. |
03/20/2023
| Implemented |
| 6400.32(r)(4) | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. Individual #2 had a "coin key" lock on their bedroom door and this type of lock does not allow immediate access. | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. | The agency has installed the proper keyed locks for the door. (Please see image emailed) |
03/20/2023
| Implemented |
| 6400.34(a) | 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 #1's Individual rights were signed on 1/12/22 and then they were not signed again until 3/1/23. This exceeds the requirement. | 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. | The staff did not provide the rights within the time prescribed. At time of inspection the rights were presented to the individual and he signed the document. |
03/20/2023
| Implemented |
| 6400.166(a)(11) | Individual #1's March 2023 Medication Administration Record (MAR) did not include the diagnosis or purpose for the following medications: Allergy relief, Aripiprazole, Fluoxetine, Lisinopril, and Amphet/Dextr. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | The staff persons wrote the reason/purpose for the medication for correction. (Please see image sent via email) |
03/20/2023
| Implemented |
| 6400.169(a) | The agency utilized the Department's Modified Medication Administration Training Course, but Staff #1 only had documentation of being observed administering medications one time. The Modified Medication Administration Training Course requires that staff must be observed administering medications four times by a Certified Medication Administration Trainer or a Qualified Medication Administration Practicum Observer, and the staff must be observed applying proper handwashing and gloving techniques one time by a Certified Medication Administration Trainer. Staff #1 has not successfully completed Department-approved medication administration course. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | The staff person has completed the required medication Pass Observations. (Please see image sent via email) |
03/20/2023
| Implemented |
| 6400.182(c) | Individual #1's Individual Support Plan (ISP) states they need assistance managing money as they are still learning skills for managing money. Individual #1 will be able to carry $10 on him at all times. However, Individual #1's assessment dated 3/12/22 under financial independence states they are a "5" which is Independ for making small purchases, and a "5" as being independent with discriminates amounts of currency. The individual plan shall be revised when an individual's needs change based upon a current assessment. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The staff have reached out to the Supports Coordinators requesting a meeting to correctly document the needs of the individual in the ISP. |
04/30/2023
| Implemented |