| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | The home does not maintain an up-to-date financial record for Individual #1. Financial records from October 2022 to August 2023 were not available. | 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. | Financial Records were located and present in the Program Managers office. Due to short staffing, records were not filed in client file. Program Manager has since filed financial records and all are accounted for. |
12/31/2023
| Implemented |
| 6400.67(b) | Surfaces are not free of hazards. The light fixture above the dining room table was missing a bulb, creating a potential hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Program Manager directed staff to replace light bulb at time of correction. Physical Site Checklists have a specific section in regards to all fixtures having light bulbs. Staff will be retrained on the aforementioned regulation. |
12/31/2023
| Implemented |
| 6400.107 | The home has two bedrooms with portable space heaters situated on the wall just below the ceiling. These space heaters were not hard-wired with permanent connectors and not permanently installed. | Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including staff rooms.
| Space Heaters will be removed from individuals bedrooms. Maintenance has been contacted for removal. |
12/31/2023
| Implemented |
| 6400.112(d) | Fire drills shall be completed in under 2 minutes, 30 seconds. The home has an extended evacuation time of 3 minutes. The fire drills conducted on 6/28/23, 7/21/23, 5/23/23, 4/15/23, 3/23/23, and 10/17/22 was unsuccessful drills as two individuals refused to evacuate the home on 7/21/23, 6/28/23, and 10/17/22. One individual Refused to evacuate the home on 5/23/23, 4/15/23 and 3/23/23. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | Program Manager of the home will review fire safety concerns with all individuals and provide schedule a time for the fire chief to give additional training to consumers. All team members will be made aware of concerns regarding previously failed fire drills will be discussed so that actionable plans can be implemented to prevent reoccurrence. Fire Chief will be scheduled to assess whether or not the home requires an extended evacuation time. |
12/31/2023
| Implemented |
| 6400.113(a) | Individual #1 was not trained annually in fire safety. Individual #1's most recent fire safety training was completed on 12/8/21. | 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. | Individual Rights were located and present in the Program Managers office. Due to short staffing, paperwork was not filed in client file. Program Manager has since filed all paperwork that was not in client file. |
12/31/2023
| Implemented |
| 6400.141(a) | Individual #1 did not have a physical examination completed annually. The most recent physical examination was completed on 7/25/22. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Physical Exam located and present in the Program Managers office. Due to short staffing, paperwork was not filed in client file. Program Manager has since filed all paperwork that was not in client file. |
12/31/2023
| Implemented |
| 6400.142(a) | Individual #1 did not have a dental examination completed at least annually. Individual #1's most recent dental examination was completed on 12/28/21. | 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. | Dental Exam located and present in the Program Managers office. Due to short staffing, paperwork was not filed in client file. Program Manager has since filed all paperwork that was not in client file. |
12/31/2023
| Implemented |
| 6400.211(b)(1) | Individual #1's emergency information did not include the name, address and telephone number of a person designated to be contacted in case of emergency. The information documented was for a former employee of the agency. | Emergency information for each individual shall include the following: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency.
| Emergency Information was updated to reflect current Program Manager. |
12/31/2023
| Implemented |
| 6400.34(a) | Individua #1 was not informed of the Individual's individual rights. Individual #1 was most reenly informed of the Individual's rights on 12/8/21. | 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. | Individual Rights were located and present in the Program Managers office. Due to short staffing, paperwork was not filed in client file. Program Manager has since filed all paperwork that was not in client file. |
12/31/2023
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medications to treat symptoms of psychiatric illness. Individual #1 has not had a review of these medications since 10/6/22. | 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. | Three Month Med Reviews were located and present in the Program Managers office. Due to short staffing, paperwork was not filed in client file. Program Manager has since filed all paperwork that was not in client file. |
12/31/2023
| Implemented |
| 6400.194(d) | Individual #1 has a Restrictive Procedure Plan. There is not documentation of the use of a human rights team to review the plan since 4/22/20. | A record of the human rights team meetings shall be kept. | Human Rights Records were located and present in the Program Managers office. Due to short staffing, paperwork was not filed in client file. Program Manager has since filed all paperwork that was not in client file. |
12/31/2023
| Implemented |