| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Clean and sanitary conditions are not maintained in the home. The ceiling fan located in the living room was covered in dust. | Clean and sanitary conditions shall be maintained in the home. | the lead staff of the site cleaned the ceiling fan on 4-19-23 and will maintain it every week of dust. |
04/19/2023
| Implemented |
| 6400.67(b) | The home is not free of hazards. There is a sewer drainpipe sticking up out of the sidewalk in the front of the home, creating a tripping hazard. There is a piece of wood on the back deck of the home that is rotted and sagging, creating a hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | the landlord was contacted about the hazardous areas and he contracted with a construction company to come out and fix the boards on the deck and the front sidewalk with the sewer pipe. the contractors came out on 5-4-23 and it was raining they were unable to fix the areas. they are scheduled to come back out on 5-31-23 to fix all items. |
04/20/2023
| Implemented |
| 6400.106 | The furnace inspection in the home was completed late. The furnace was inspected on March 18, 2022, and not again until April 14, 2023. | 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.
| a tracking compliance record has been created to monitor compliance in all inspections. |
04/20/2023
| Implemented |
| 6400.141(c)(8) | Individual #2 had a late mammogram. Individual #1 has a mammogram completed on 3/14/22 with instructions to schedule the next mammogram after March 15, 2022. Individual #1's annual mammogram was not scheduled until May 26, 2023. There is no documentation indicating when the appointment was scheduled for May 26, 2023. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | the lead staff will keep track of all appointments and annuals and will schedule appointments as needed. documentation will be kept if the office is unable to get the individual in within the grace period of the last annual. |
04/20/2023
| Implemented |
| 6400.181(e)(12) | Individual #1's annual assessment dated 9/27/22 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. | Section 4 of the assessment has the recommendations for specific areas of training, appointments and services; however, we will make it more prominent in the assessment the areas and elaborate on each section more. |
04/28/2023
| Implemented |
| 6400.181(e)(13)(i) | Individual #2's annual assessment dated 9/27/22 does not address progress and growth over the past 365 days 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. | an additional section of the plan has been added to address the progress that was made from the last assessment to the current one in the area of Health. the progress will be labeled separately in the assessment. |
04/28/2023
| Implemented |
| 6400.181(e)(13)(ii) | Individual #2's annual assessment dated 9/27/22 does not address progress and growth over the past 365 days in motor and communication skills. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | an additional section of the plan has been added to address the progress that was made from the last assessment to the current one in the area of motor and communication skills. the progress will be labeled separately in the assessment. |
04/28/2023
| Implemented |
| 6400.181(e)(13)(iii) | Individual #2's annual assessment dated 9/27/22 does not address progress and growth over the past 365 days in activities of daily living. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | an additional section of the plan has been added to address the progress that was made from the last assessment to the current one in the area of activities of daily living. the progress will be labeled separately in the assessment. |
04/28/2023
| Implemented |
| 6400.181(e)(13)(iv) | Individual #2's annual assessment dated 9/27/22 does not address progress and growth over the past 365 days personal adjustment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | an additional section of the plan has been added to address the progress that was made from the last assessment to the current one in the area of personal adjustment. the progress will be labeled separately in the assessment. |
04/28/2023
| Implemented |
| 6400.181(e)(13)(v) | Individual #2's annual assessment dated 9/27/22 does not address progress and growth over the past 365 days in socialization. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | an additional section of the plan has been added to address the progress that was made from the last assessment to the current one in the area of socialization. the progress will be labeled separately in the assessment. |
04/28/2023
| Implemented |
| 6400.181(e)(13)(vi) | Individual #2's annual assessment dated 9/27/22 does not address progress and growth over the past 365 days 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. | an additional section of the plan has been added to address the progress that was made from the last assessment to the current one in the area of recreation. the progress will be labeled separately in the assessment. |
04/28/2023
| Implemented |
| 6400.181(e)(13)(vii) | Individual #2's annual assessment dated 9/27/22 does not address progress and growth over the past 365 days in financial independence. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| an additional section of the plan has been added to address the progress that was made from the last assessment to the current one in the area of financial independence. the progress will be labeled separately in the assessment. |
04/28/2023
| Implemented |
| 6400.181(e)(13)(viii) | Individual #2's annual assessment dated 9/27/22 does not address progress and growth over the past 365 days in manage 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. | an additional section of the plan has been added to address the progress that was made from the last assessment to the current one in the area of managing personal property. the progress will be labeled separately in the assessment. |
04/28/2023
| Implemented |
| 6400.181(e)(13)(ix) | Individual #2's annual assessment dated 9/27/22 does not address progress and growth over the past 365 days 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. | an additional section of the plan has been added to address the progress that was made from the last assessment to the current one in the area of community integration. the progress will be labeled separately in the assessment. |
04/28/2023
| Implemented |
| 6400.46(d) | Staff #2 was hired on 1/20/21. Staff #2 did not receive annual training by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques, and cardio-pulmonary resuscitation. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | the staff is scheduled to have CPR and First Aide training on May 26, 2023 by a trained professional with the American Red Cross. |
05/18/2023
| Implemented |
| 6400.165(a) | Individual #2 is prescribed Levothyroxine 50mcg, take 1 tablet by mouth daily at least 30 minutes prior to breakfast or other meds for thyroid. This medication was administered on April 1 and April 2, 2023, however it was not documented as administered at the time of administration. | A prescription medication shall be prescribed in writing by an authorized prescriber. | the staff that actually gave that medication had to retake the medication class over so that they were trained in the new medication administration course thru university of Mass. |
04/23/2023
| Implemented |