| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.110(e) | At 1:25PM on 1/5/2023, the smoke detectors in the three-story home were not interconnected. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | 1. All interconnected smoke/carbon monoxide detectors have been replaced immediately and tested to ensure that they are working properly within hours of discovery on 1/5/2023. Alarms were sourced at Lowes and installed immediately by , certified fire inspector. |
01/05/2023
| Implemented |
| 6400.181(e)(1) | Individual #1's assessment, completed 6/28/2022, does 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. | 1. , Program Specialist has performed a thorough and thoughtful new assessment on all individuals. Completed on 2/7/2023.
2. Reviewed by the Administration team. on 2/7/2023. |
02/22/2023
| Implemented |
| 6400.181(e)(3)(iii) | Individual #1's assessment, completed 6/28/2022, does not include the individual's current level of performance in personal adjustment. | The individual's current level of performance and progress in the following areas: Personal adjustment. | 1., Program Specialist has performed a thorough and thoughtful new assessment on all individuals. Completed on 2/7/2023.
2. Reviewed by Administration team on 2/7/2023 |
02/22/2023
| Implemented |
| 6400.181(e)(9) | Individual #1's assessment, completed 6/28/2022, does 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. | 1. Program Specialist has performed a thorough and thoughtful new assessment on all individuals. Completed on 2/7/2023.
2. Reviewed by Administration team on 2/7/2023 |
02/22/2023
| Implemented |
| 6400.181(e)(12) | Individual #1's assessment, completed 6/28/2022, does not include recommendations for specific areas of training, programming and services. This section was left blank. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | 1. Program Specialist has performed a thorough and thoughtful new assessment on all individuals. Completed on 2/7/2023.
2.Reviewed by Administration team on 2/7/2023 |
02/22/2023
| Implemented |
| 6400.181(e)(13)(i) | Individual #1's assessment, completed 6/28/2022, does not include the individual's 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.
| 1.Program Specialist has performed a thorough and thoughtful new assessment on all individuals. Completed on 2/7/2023.
2. Reviewed by Administration team on 2/07/2023 |
02/22/2023
| Implemented |
| 6400.181(e)(13)(vi) | Individual #1's assessment, completed 6/28/2022, does not include the individual's 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. | 1. TProgram Specialist has performed a thorough and thoughtful new assessment on all individuals. Completed on 2/7/2023.
2. Reviewed by Administration team on 2/7/2023 |
02/22/2023
| Implemented |
| 6400.181(e)(13)(viii) | Individual #1's assessment, completed 6/28/2022, does not include the individual's 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. | 1. Program Specialist has performed a thorough and thoughtful new assessment on all individuals. Completed on 2/7/2023.
2. Reviewed by Administration team on 2/7/2023 |
02/22/2023
| Implemented |
| 6400.181(e)(13)(ix) | Individual #1's assessment, completed 6/28/2022, does not include the individual's 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. | 1. , Program Specialist has performed a thorough and thoughtful new assessment on all individuals. Completed on 2/7/2023.
2. Reviewed by Administration team on 2/7/2023 |
02/22/2023
| Implemented |
| 6400.15(b) | The agency completed a self-assessment of the home on 12/30/2022; however, the agency did not use the Department's most current licensing inspection instrument (reflecting regulatory changes promulgated in February 2020) to measure and record compliance for this chapter. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | On 2/7/2023 CEO was able to obtain the proper self-assessment form to be performed one each home 3-6 months prior to license expiration.
On 2/7/2023, CEO performed the self-assessment on each home. |
02/07/2023
| Implemented |
| 6400.163(g) | At 12:53PM on 1/5/2023, one half of an Olanzapine ODT was loose on the bottom of Individual #1's medication container. | Prescription medications shall be stored in an organized manner under proper conditions of sanitation, temperature, moisture and light and in accordance with the manufacturer's instructions. | on 2/5/2023 All employees that give medications at this location were assigned a training out of our Relias training portal called. "Medication Administration: Orals" the description of the training is as follows; This course will present the do's and don'ts of oral medication administration for solid, crushed, split, and liquid medications. This has a due date of 2/20/23.
Assigned by: Shannan Williams, CEO |
02/20/2023
| Implemented |