| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self-assessments were not completed by evaluating each line item on the self-assessment tool for all 3 homes. | 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 self assessment was completed on 4/30/18 and an evaluation on each line item was individually attended to and completed. All Self-assessments will be evaluated line by line to ensure the correct information is being implemented on form. A copy of the Self-assessment will be forwarded as evidence,. |
04/30/2018
| Implemented |
| 6400.77(b) | No scissors in first aid kit. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | A first aid kit with all the 6400 regulated items was purchased on 6/15/18. All program staff will be trained on what items needs to be inside of the kit at all times to ensure safety of all individuals. The newly purchased first aid kit receipt will be forwarded as evidence. |
06/15/2018
| Implemented |
| 6400.141(a) | No initial physical exam completed. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The physical was conducted on 2/8/18 but was missing key information. Individual #1 did not have a PPD conducted during her physical on 2/8/18. A PPD was conducted on 4/17/18 and a negative result was determined on 4/19/18. The form was left at the Doctor's office and a new form was illustrated and completed on 4/30/18. The program staff will be trained on learning the importance of completing all forms and returning them to their supervisor. A copy of individual #1 physical will be forwarded as evidence. |
04/30/2018
| Implemented |
| 6400.142(a) | No dental exam completed. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | The program specialist contacted "Elite Dental" to obtain all the necessary information and a dental plan was completed for individual #1 on 4/30/18. A copy of the plan will be forwarded as evidence. |
04/30/2018
| Implemented |
| 6400.181(a) | No initial assessment completed. | 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. | individual #1 assessment was completed on 4/30/18.
as a plan of correction all initial assessments will be conducted within the 60 day period and annual assessments will be completed within the 1 yr. time frame of their scheduled date to be in compliance with the 6400 regulations. An example of the completed assessment will be forwarded as evidence. |
04/30/2018
| Implemented |