| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.101 | There is a turn lock mechanism on the basement side of the door, leading from the basement to the garage, posing an obstructed egress when engaged. There is not a man door inside the garage. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| On 1/5/2023, The door knob was turned to absolve the obstructed egress. |
01/05/2023
| Implemented |
| 6400.151(a) | Program Specialist #1, date of hire 10/1/2021, had an initial physical examination completed on 7/15/2022. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Compliance with required credentials has been noted. ie: (Physical, TB, CPR, Medication Training, annual training.)
Program Specialist #1 has her physical, but it was done four days after receiving our first client on 7/11/2022. |
01/05/2023
| Implemented |
| 6400.181(e)(12) | Individual #1's assessment, completed 10/24/2022, does not include recommendations for specific areas of training, programming and services. This section reads, "N/A." | 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)(ix) | Individual #1's assessment, completed 10/24/2022, does not include the individual's current level in community integration. This sections reads, "N/A." | 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 |
| 6400.182(c) | Individual #1's, Individual Service Plan, completed 9/22/2022, reads, Individual #1 "ENJOYS SWIMMING AND NEEDS SUPERVISION AROUND SWIMMING POOLS, LAKES AND LARGE BODIES OF WATER." individual #1's assessment, completed 10/24/2022, reads that individual is able to swim and can independently swim in a swimming pool. Individual #1's, Individual Service Plan, completed 9/22/2022, states, Individual #1 "IS UNABLE TO REGULATE HER OWN TEMPERATURE AND HER STAFF HAS STATED THAT [Individual #1] WILL MAKE HER WATER TOO HOT." individual #1's assessment, completed 10/24/2022, assessed that the individual #1 is able to regulate her water temperature. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | 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
3. Program Specialist, requested a revision to this individual's plan on 2/8/2023 to reflect that she can regulate her own shower water . The SC replied on 2/10/23 that the revision was made
4. Update has been made in HCSIS to the individual's ISP, it has been Printed and placed in the Individual's binder in the home and office. |
02/08/2023
| Implemented |