| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | There was a purchase made on 3/30/22 with Ind. #14 funds for $153.02 for an upholstered headboard, however this item was not on their bed or anywhere in the home. When staff who has worked in this home for 3 years, was asked if Ind. #14 has a headboard, they stated that no and that they have never had a headboard. | Individual funds and property shall be used for the individual's benefit. | 1. Incident # _9134218_______ has been filed and an investigation is underway. |
12/09/2022
| Implemented |
| 6400.67(a) | The basement wall in the finished basement area behind the door has a hole in the wall and the surrounding area around the hole is very soft as though there is some active water damage happening behind that wall | Floors, walls, ceilings and other surfaces shall be in good repair. | 1. The agency contractor was dispatched to the home and repaired the hole in the basement and assessed potential water issue. |
12/09/2022
| Implemented |
| 6400.67(b) | In the main unfinished basement area, there is mold on the drywall going from the screen to about a foot up the wall. | Floors, walls, ceilings and other surfaces shall be free of hazards. | 1. The agency contractor was dispatched to the home and removed the drywall with the ¿mold¿ present. |
12/09/2022
| Implemented |
| 6400.68(b) | The bathroom water temperature measured 129.9 degrees Fahrenheit. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The agency sent a plumber to the home to immediately to assess the water heater and lower the temperature. |
12/09/2022
| Implemented |
| 6400.72(b) | There is a hole in the living room window screen. | Screens, windows and doors shall be in good repair. | 1. The agency contractor was dispatched to the home and repaired the screen. |
12/09/2022
| Implemented |
| 6400.76(a) | Ind. #14 bedroom dresser has multiple drawers that are off the hinges and could not be put back on the hinges. | Furniture and equipment shall be nonhazardous, clean and sturdy. | 1. The agency purchased dresser for individual #14 |
12/09/2022
| Implemented |
| 6400.181(e)(3)(iv) | Ind. #14, 8/9/22 assessment states via the providers number system used (5) that they are independent in property management, but in the comments, it states that they require assistance with property management and managing personal possessions. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal needs with or without assistance from others. | 1. Individual #14¿s assessment was corrected to have the comment section say ¿none¿ as it is accurate that he is independent with property management. |
12/09/2022
| Implemented |
| 6400.32(i) | In the house manager's locked office closet, there was a bag of clothes that were purchased for Ind. #14 while he was in school on 9/7/22. These clothes had a missing t-shirt, undershirt and pants when compared to the receipt purchase. Staff states that he was given these clothes today to wear and that is why they are not in the bag. There were also two bags of Ind. #14 winter clothes being stored in the basement and the direct support staff stated that they were instructed to place these there to clear up space in his bedroom and to help him not wear weather inappropriate clothing. There is no documentation of this in his behavior support plan, restrictive plan, or individual plan, so in the absence of that this practice is a violation of the individuals rights to have access to their personal belongings. | An individual has the right of access to and security of the individual's possessions. | 1. All clothing items were organized and placed in the individual¿s bedroom
EIM # 9134227 has been entered. |
12/09/2022
| Implemented |
| 6400.165(g) | Ind. #14, 11/8/21, 2/3/22, 5/5/22 and 8/4/22 psychotropic medication reviews states that the medications should continue, but it does not state what those medications are or the required dosage. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | 1. The Program Director and Program Supervisor are responsible to ensure that documentation from medical appointments are complete and accurate. |
12/09/2022
| Implemented |