| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(a) | Individual 1's finances were not adequately accounted. for. Disbursements were made on a blank sheet of paper without counting change. Deposits also were not tracked, unknown how much money the individual has outside of petty cash disbursement hand written on sheet. Cash was short 47.25 in December 2020. The agency did not have a formal ledger that tracks such purchases and deposits. | There shall be a written policy that establishes procedures for the protection and adequate accounting of individual funds and property and for counseling the individual concerning the use of funds and property. | A staff financial Accountability form was developed in April of 2021 (Supporting Document #1). A new fiscal management policy was drafted in May of 2021 (Supporting Document #2). |
05/03/2021
| Implemented |
| 6400.112(e) | 3914 Cedar Lane did not have a documented sleep drill every 6 months.
January's fire drill form dated 1/5/2021 notated a possible overnight drill on January 21 at 10pm directly on that form, but did not document the exit used, location , meeting area and time it took to evacuate. | A fire drill shall be held during sleeping hours at least every 6 months. | In the future overnight drills will be conducted at least every 4 months. In the future to allow adequate time for administrative review, all fire drills will preferably be completed by the 15th of each month. The Director of Residential Services is responsible for reviewing fire drills and ensuring a satisfactory and compliant fire drill is completed each month. |
05/19/2021
| Implemented |
| 6400.113(a) | Fire safety training was not completed annually for individual 1, most recent training was completed on 3/24/2020. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | Upon starting, the Director of Residential recognized fire training, human rights, and assessments were out of date. Director completed all of this documentation in March of 2021. |
04/01/2021
| Implemented |
| 6400.141(c)(6) | Tuberculin test was not read with negative results every two years. Last documented test was read on 12/6/2018 for individual 1. Physician stated it wasn't needed but there was no reason stated and no waiver request was submitted to the department. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | A TB test was actually completed on 3/3 and read on March 4 (Supporting document #14) however, this was not in the file at the time of inspection. |
04/01/2021
| Implemented |
| 6400.151(a) | The physical exam was not completed every two years for staff 1. Staff had a check up on 2/27/2020. Unable to verify a general exam was completed and if the staff is free from communicable diseases. | 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. | A physical for this staff is scheduled to be completed 5/18/21. |
04/01/2021
| Implemented |
| 6400.181(a) | The assessment was not completed annually for individual 1, 11/6/2020 was the currently dated assessment. The assessment prior was completed 8/20/18 | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | To prevent reoccurrence, a tracking grid for program specialist paperwork such as assessments has been developed (Supporting Document 3). The Director of Residential Services is responsible for completing and filing all required Program Specialist paperwork within required time frame. The Executive Director will be responsible for reviewing these grids monthly with the residential director. |
04/01/2021
| Implemented |
| 6400.181(c) | The assessment dated 11/6/2020 for individual 1 did not notate what it was based on. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | The assessment form has been revised to include a space for describing the source material for the content of the assessment (Supporting document #7). |
03/30/2021
| Implemented |
| 6400.34(a) | Documentation that Individual rights were reviewed with individual 1 was not completed annually and was not provided at inspection. Rights were not reviewed with the individual during 2020 licensing year.
Individual Rights were recently signed on 3/24/2021 after licensing requested the document and are now current. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Upon starting, The Director recognized fire training, human rights, and assessments were out of date. Director completed all of this documentation in March of 2021. |
04/01/2021
| Implemented |
| 6400.169(d) | Record of Medication administration training was not kept for staff 1. Unable to verify the record of the training certification from 10/9/20 to 2/20/2021. | A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed. | Upon starting, The Director of Residential recognized that Staff 1¿s medication administration training documentation was lacking. Thus, staff was retrained on 2/13/21. |
03/31/2021
| Implemented |
| 6400.181(f) | Documentation that the assessment dated 11/6/2020 for individual 1 was sent to all team members at least 30 days prior to the individual plan meeting was not provided. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | In the future the Director of Residential Services will be responsible for sending the assessment to all team members at least 30 days prior to the start of an ISP meeting. The Executive Director responsible for overseeing the Residential Director. |
04/01/2021
| Implemented |