| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.81(k)(6) | Individual #1's bedroom did not have a mirror. | In bedrooms, each individual shall have the following: A mirror. | Maintenance Team placed a mirror in individual 1 bedroom. |
01/16/2024
| Implemented |
| 6400.110(e) | The basement smoke detector was not interconnected with the other smoke detectors on other floors. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | Maintenance team reprogrammed all smoke detectors in home to assure they were interconnected. House Manager face timed the inspector on 12/1/23 to show it was done. |
12/01/2023
| Implemented |
| 6400.141(c)(3) | No immunizations record is on file for Individual 1. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | The physical form was amended by the Director fo Health Services to include immunization record. A request was made to primary care physician to obtain immunization record |
01/01/2024
| Implemented |
| 6400.141(c)(6) | The TB test was not received for Individual 1. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | A prescription was requested on 1 24.23 for a TB test to be administered to individual . Upon receipt of prescription house manager and or staff will take him to get the TB test |
01/24/2024
| Implemented |
| 6400.141(c)(14) | Information pertinent to diagnosis and treatment in case of an emergency was not addressed on the 11/28/22 physical examination for Individual 1. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The physical form was amended to include medical information pertinent to diagnosis and treatment in case of an emergency. |
01/01/2024
| Implemented |
| 6400.142(g) | No dental hygiene plan was written for Individual 1. | A dental hygiene plan shall be rewritten at least annually. | Director of Health Services amended dental form to include a dental hygiene plan. During next dental visit new form will be taken and completed. |
01/01/2024
| Implemented |
| 6400.181(c) | Individual 1's assessment did not indicate that it was based on instruments, interviews, progress notes, observations: as it relates to the annual assessment. (No noted source of information.) | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | Program Specialist revised form to include how assessment was completed |
01/01/2024
| Implemented |
| 6400.181(e)(12) | Recommendations are not addressed in Individual 1's annual assessment for services, training, and programming. It references going out with the grandfather and the YMCA. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Program Specialist revised assessment to include recommendations for specific areas of training, programming and services. |
01/01/2024
| Implemented |
| 6400.181(e)(13)(vii) | The financial independence section is not addressed in the current annual assessment for Individual 1. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| The Program Specialist revised assessment to include progress concerning financial independence |
01/01/2024
| Implemented |
| 6400.181(f) | There was no record indicating if Individual 1's assessment was sent to the plan team members at least 30 days before ISP team meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Program Specialist emailed assessment to Supports Coordinator |
01/24/2024
| Implemented |
| 6400.183(c) | A list showing that the ISP team met or was present/participated in the annual ISP meeting for Individual 1 was not on file at time of the review. | The list of persons who participated in the individual plan meeting shall be kept. | The Program Specialist emailed to request previous year signature page for ISP meeting. Moving forward Program Specialist will add signature page to individual profile upon completion of annual ISP meeting. |
01/24/2024
| Implemented |
| 6400.213(1)(i) | Individual 1's record does not list identifying marks. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Director fo Health Services amended face sheet for individual 1to include all identifying marks. |
01/24/2024
| Implemented |