| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.81(h) | On 6/5/2024 at approximately 10:11am, the three windows in Individual #1's bedroom, located on the exterior wall above the individual's bed, were observed with a tinted privacy film that covered the entirety of all three windows. The film was restricting the individual's view to the outside. | Each bedroom shall have at least one exterior window that permits a view of the outside. | THE CEO MET WITH INDIVIDUAL #1 BEHAVIOR SPECIALIST TO MAKE SURE HIS RESTRICTIVE PROCEDURE PLAN WAS UPDATED; THE TINTED PRIVACY FILM WAS ADDED TO HIS RESTRICTION PLAN. ON 6/6/2024 THE CEO MET WITH HUMAN RIGHT TEAM TO REVIEW THE PLAN AND IT WAS APPROVED. |
06/07/2024
| Implemented |
| 6400.141(c)(1) | Individual #1's physical examination, completed on 3/13/2024, did not include a review of the individual's previous medical history. A section to detail the individual's previous medical history was omitted from the physical examination form template. | The physical examination shall include: A review of previous medical history. | THE INDIVIDUAL #1 PHYSICAL FORM HAS BEEN UPDATED TO INCLUDE INDIVIDUAL PREVIOUS MEDICAL HISTORY CHECKLIST. THIS FORM HAS BEEN ADDED TO HID MEDICAL BINDER. |
06/07/2024
| Implemented |
| 6400.32(e) | On 6/5/2024 at approximately 10:03am, the cold-water faucet in the kitchen sink was inoperable. Direct Service Worker #2 stated that the cold water was turned off as Individual #1 likes to play in the kitchen sink. The cold water had been shut off using the valve under the kitchen sink, prohibiting the individual from turning on the cold water. | An individual has the right to make choices and accept risks. | STAFF ON SHIFT ON 6/5/2024 OPENED THE COLD-WATER VALVE UNDER THE SINK IMMEDIATELY. |
06/07/2024
| Implemented |
| 6400.32(h) | On 6/5/2024 at approximately 10:33am, cameras were observed in the front corner of the dining room, in the bedroom hallway above the entrance into the kitchen, and on the exterior corner of the home facing the front door. According to Chief Executive Officer #1, the cameras are only equipped to provide a live feed do not record. Chief Executive Officer #1 has access to the live feed from his cellular device. Individual #1 does not have signed consent to videography. | An individual has the right to privacy of person and possessions. | THE CEO SENT WRITTEN CONSENT AGREEMENT OF USE OF CAMERA AT THE COMMON AREA OF THE HOME TO INDIVIDUAL#1 GUARDIAN. HIS GUARDIAN SIGNED AND SENT IT BACK VIA EMAIL. |
06/06/2024
| Implemented |
| 6400.34(a) | Individual #1 was informed of their rights and the process to report a rights violation on 4/26/2024. The review of rights on 4/26/2024 did not include the individual's right to speak freely as referenced in § 6400.32(b) nor did the review include that the individual's rights may only be modified in accordance with § 6400.185 to the extent necessary to mitigate a significant health and safety risk to the individual or others as referenced in § 6400.32(v). | 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. | THE CEO UPDATED INDIVIDUAL#1 CLIENT RIGHTS WHICH REFECTS 6400.185, 6400.32B AND 6400. 32V.INDIVIDUAL#1 SIGNED THE UPDATED CLIENT RIGHT. THE RIGHT HAS BEEN ADDED TO HIS PROGRAM CHART. |
06/06/2024
| Implemented |
| 6400.195(c)(8) | Individual #1, date of admission 4/26/2024, had a Restrictive Procedure Plan developed on 1/13/2024 prior to their admission into the agency. The Restrictive Procedure Plan indicates on page 5 that "The direct care staff from Full Scope monitor 24-7 and document behaviors on attached data sheet." According to Chief Executive Officer #1, Individual #1 no longer receives services through Full Scope. The Restrictive Procedure Plan has not been updated to indicate the person responsible for monitoring and documenting progress with the behavior support component of the individual plan. | The behavior support component of the individual plan shall include: The name of the staff person responsible for monitoring and documenting progress with the behavior support component of the individual plan. | THE CEO MET WITH THE BEHAVIOR SPECIALIST TO MAKE SURE THE BEHAVIOR SUPPORT PLAN IS UPDATED.
THE PLAN WAS UPDATED AND IT HAS BEEN ADDED TO HIS PROGRAM CHART. |
06/07/2024
| Implemented |
| 6400.213(1)(i) | 213()ii Individual #1's demographic form did not include the individual's height, weight, and eye color. These sections of the demographic form were left blank. Individual #1's demographic form did not include identifying marks. This section had been omitted from the demographic form template. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | ON 6/5/2024 INDIVIDUAL#1 DEMOGRAPHIC FORM HAS BEEN UPDATED TO INCLUDE HEIGHT, WEIGHT, EYE COLOR AND IDENTIFYING MARKS.THIS FORM HAS BEEN ADDED TO HIS PROGRAM CHART |
06/06/2024
| Implemented |