| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | On 10/29/2024, the agency's self-assessment of the home did not contain an end/completion date of the assessment; therefore, compliance could not be measured. Additionally, the following 6400 regulations were not addressed and left blank: 11, 14b, 14c, 15b, 15c, 16, 18g, 18i, 18j1, 22c, 22d2, 22e1, 22e2, 24 under General Requirements; 31e under Individual Rights; 69c, 73a, 74, 81c, 81g under Physical Site; 106, 109a, 109b, 110d, 111d, 111f, 110g under Fire Safety; 141c9 under Individuals Health; 169b1, 169b2 under Medications; 181d under Assessments; 195c5, 195d under Plan development/Process/Content; 190a2, 190b, 190c under Day Services/Recreational and Social Activities; 214c under Individuals Records; 233, 237b, 240c under Nine or more Individuals; 262b1, 262b2, 262b3, 262b4, 262b5, 263 under Respite Care. | 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.
| The Director of Programs will complete the self assessment issued by ODP. The Director of Programs will complete the self assessment between June and September prior to the expiration of the certificate of compliance. Areas of non - compliance will be addressed by the director of programs to ensure compliance. |
11/20/2024
| Implemented |
| 6400.141(c)(11) | Individual #1's physical examination, dated 9/19/2024, did not address health maintenance needs. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | The provider will ensure that physical forms are completed in its entirety. The Program Specialist will ensure all components of the physical forms and any other pertinent medical questions are answered. Prior to uploading physical forms into the agency shared drive, the Program Specialist will review the medical forms submitted by DSP staff. |
11/01/2024
| Implemented |
| 6400.141(c)(12) | Individual #1's physical examination, dated 9/19/2024, did not address physical limitations. | The physical examination shall include: Physical limitations of the individual. | The Program Specialist will ensure all components to the physical form are completed in its entirety prior to uploading forms into the agency shared drive. |
11/01/2024
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination, dated 9/19/2024, did not address medical information pertinent to diagnosis and treatment in case of emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The Program Specialist will ensure the at the individual physical form is completed in its entirety. The Program specialist will ensure that all components are completed on the form prior to uploading the forms into the agency shared drive. |
11/01/2024
| Implemented |
| 6400.141(c)(15) | Individual #1's physical examination, dated 9/19/2024, did not address the individual's diet. | The physical examination shall include:Special instructions for the individual's diet. | The Program Specialist will ensure that the individual form is completed in its entirety prior to uploading forms to the agency shared drive. |
11/01/2024
| Implemented |
| 6400.165(g) | Individual #1 was prescribed psychotropic medication on 10/31/2023. Psychiatric medication reviews were conducted on 6/20/2024 and 9/19/2024. This exceeds the at least every 3-month requirement. | 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. | The program specialist will ensure 3 month medication reviews are scheduled using calendar reminders and the shared agency drive. If appointments have been refused proper documentation will be gathered by the program specialist and kept in the individual file. If the appointment was cancelled by the medical provider the program specialist will obtain proper documentation and file in the individual shared drive. |
11/22/2024
| Implemented |