| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | There is not a source of outside lighting at the basement doorway exit leading to the back yard of the home. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| on 1/7/2023 a light was place at the basement doorway exit leading to the back yard of the home. |
01/07/2023
| Implemented |
| 6400.82(f) | The bathroom in the basement of the home did not have a trash receptacle and individual clean paper or cloth towels. | 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. | on 1/7/2023 a garbage receptacle and paper towels were placed in the bathroom located in the basement. |
01/07/2023
| Implemented |
| 6400.181(e)(1) | Individual #1's assessment, completed 7/11/2022, 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 Administration team on 2/7/2023 |
02/22/2023
| Implemented |
| 6400.181(e)(2) | Individual #1's assessment, completed 7/11/2022, does not include the individual's likes, dislikes and interests. | The assessment must include the following information: The likes, dislikes and interest 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 Administration team on 2/7/2023 |
02/22/2023
| Implemented |
| 6400.181(e)(9) | Individual #1's assessment, completed 7/11/2022, 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)(11) | Individual #1's assessment, completed 7/11/2022, does not include his psychological evaluation. | The assessment must include the following information: Psychological evaluations, if applicable. | The agency had the psychological evaluation, however, it was at the office location in a separate binder. |
02/07/2023
| Implemented |
| 6400.181(e)(12) | Individual #1's assessment, completed 7/11/2022, does not include recommendations for specific areas of training, programming and services. | 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 7/11/2022, 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 2/7/2023 |
02/22/2023
| Implemented |
| 6400.181(e)(13)(viii) | Individual #1's assessment, completed 7/11/2022, 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 7/11/2022, 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 |