| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.46(a) | Direct Service Worker #1, date of hire 10/24/22, received initial fire safety training on 11/28/22. | Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | The employee identified is no longer employed with the agency. The orientation curriculum in Relias has been updated to include general fire safety. All current employees have completed the required general fire safety, evaluation procedures and responsibilities. |
07/21/2023
| Implemented |
| 6400.46(c) | Direct Service Worker #1, date of hire 10/24/22, received initial first aid training on 12/19/22. | Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home shall be trained before working with individuals in first aid techniques. | Direct Service Worker # 1 is no longer employed with the agency. All current employees have received their initial first aid training. The Relias cirriculum has been updated to include initial first aid training. |
07/21/2023
| Implemented |
| 6400.165(g) | Individual #1 had a psychiatric medication review completed on 05/03/23, and then again on 05/16/23. Neither appointment form included the name or dosage of the medication listed. It was recorded as "see attached" with nothing attached to the form. | 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 psychiatry forms have been sent back to the psychiatrist to complete the missing information. The psychiatrist form has been updated to a new version that makes it more visible for the psychiatrist to see where to document the medications and dosage. |
07/28/2023
| Implemented |