| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self-assessment completed for the home was not dated. Compliance with the required timeframe could not be determined. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| CEO met with Program Manager to review regulation and discuss citation. Program Manager indicated that they understood citation and would correct moving forward. |
11/30/2024
| Implemented |
| 6400.22(d)(1) | Individual #1 has resided in the home since 6/4/24. There was no up to date property record of personal possessions deposited with the home upon admission. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | IHRS is developing a record of property and possessions for the individual, |
11/30/2024
| Implemented |
| 6400.104 | The notification to the local fire department letter presented was dated 9/26/23. The letter noted that four ambulatory individuals lived in the home. The fire letter was not updated to note the admission of Individual #1. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Program Managers will be retrained on the above regulation. All fire department letters will be reviewed and updated by the Program Manager for all locations. Letters will be submitted to Quality Assurance and Regulatory Compliance Manager for review. |
11/30/2024
| Implemented |
| 6400.112(c) | The exit used for the fire drills conducted on 6/30/24 and 11/8/23 were not noted on the fire drill form as required.
(Repeat Violation 9/2023) | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Program Manager and CEO met to discuss concerns of repeat violation. Program Manager understands that issues like this moving forward will be subject to disciplinary action. Program Manager presented CEO with checklist to ensure fire drills are not missed moving forward and all relevant information is present. All staff in the home will be retrained on the regulation. |
11/30/2024
| Implemented |
| 6400.113(a) | Individual #1 entered the home as emergency respite on 5/2/24 and has remained in the home. Individual #1 did not receive fire safety training in the home until 7/18/24.
(REPEAT VIOLATION 9/2023) | 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. | CEO met with Program Manager to review regulation and discuss citation. Program Manager indicated that they understood citation and would correct moving forward. |
11/30/2024
| Implemented |
| 6400.181(a) | Individual #1 entered the home as emergency respite on 5/2/24 and has remained in the home. The assessment on file for Individual #1 was not completed until 9/11/24. | 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. | CEO met with Program Manager to review regulation and discuss citation. Program Manager indicated that they understood citation and would correct moving forward. |
11/30/2024
| Implemented |
| 6400.181(e)(10) | The Lifetime Medical History section of the assessment for Individual #1 dated 9/11/24 did not contain the required information. The section contained one notation of an appointment on 9/18/24 and was not a comprehensive review as required. | The assessment must include the following information: A lifetime medical history. | CEO met with Program Manager. Program Manager was retrained on the above regulation. Program Manager was provided assessment template to ensure all assessments contain required information. |
11/30/2024
| Implemented |
| 6400.32(l) | An agency incident report completed by Staff #2 on 5/24/24 noted that Individual #1's mom wished to visit for their birthday. Individual #1's preference was not stated in the report. Report notes that Staff # 2 spoke to Individual #1's mother on the phone and informed her that "[Staff #3] said she can come with 1 guest. Notes indicate that Individual #1's mother stated "she'll bring whoever she wants & that no one is telling her anything different." Staff #2 noted their response to be "I told her she'd have to speak to the office because they only approved (2) people to come to the house." The Individual Support Plan (ISP) does not note the need for restrictions of visitors or a plan in place to address such need. Individual #1 has the right to receive scheduled and unscheduled visitors at any time. | An individual has the right to receive scheduled and unscheduled visitors, and to communicate and meet privately with whom the individual chooses, at any time. | Program Manager will review client rights and visitation policy with staff who wrote the incident report. |
11/30/2024
| Implemented |
| 6400.34(a) | Individual #1 entered the home as emergency respite on 5/2/24 and has remained in the home. Individual #1 was not informed of their rights until 7/18/24. | 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. | CEO met with Program Manager to review regulation and discuss citation. Program Manager indicated that they understood citation and would correct moving forward. |
11/30/2024
| Implemented |
| 6400.166(a)(11) | Individual #1 is prescribed Vitamin D3. The October 2024 Medication Administration Record (MAR) for Individual #1 did not list the diagnosis or purpose for the medication as required | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Diagnosis was added to the Medication Administration Record |
11/30/2024
| Implemented |
| 6400.169(a) | The annual practicum training document for Staff #2 noted the training period to be from 8/10/23 to 8/10/24. The form documents two Medication Record Reviews (MRR) completed on 4/24 and 6/24. The mediation review checklist documents the completion of one MRR on 4/23/24. There was no additional documentation that the 6/24 MRR had been completed. There was no documentation in the packet to illustrate that the two required Medication Administration Observations (MAO) had been completed as required. The trainer signed on 8/10/24 indicating that Staff #2 was requalified. There was no student/staff signature on the form.
Documentation supports that the course renewal requirements were not completed as required to maintain the ability to administer medications. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | CEO met with training department. Training department ensures that that the reviews occurred and this was human error. |
11/30/2024
| Implemented |