| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | The drain located in the bathroom sink was clogged and not draining properly. | Floors, walls, ceilings and other surfaces shall be in good repair. | Residential Lead is in charge of this POC
The drain was unclogged same day. It was coincidental that drain was clogged on the day of inspection |
03/30/2022
| Implemented |
| 6400.141(a) | Individual #1did not have a physical within the year prior to their 10/7/21 admission as it was not provided. Their record contained a physical from 3/4/22. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | CEO/Program specialist would be responsible for this POC
Individual resided with Parents prior to admission and parents declined to provide physical. Going forward agency would make it mandatory for a Physical to be provided before admission |
03/30/2022
| Implemented |
| 6400.141(c)(4) | Individual #1 3/4/22 physical did not included a vision screening, as documentation was not provided. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Program specialist is responsible for this POC.
We currently have a vision exam scheduled for the 4th of May 2022 |
05/04/2022
| Implemented |
| 6400.141(c)(6) | Individual #1 TB test is out of date. The record contains a TB test from 2/27/19. | 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. | program specialist is responsible for this POC.
We have scheduled a TB test for the individual so as to have an updated record on file |
05/13/2022
| Implemented |
| 6400.141(c)(7) | Individual #1 OB/GYN exam dated 1/25/22 did not include a PAP test. Clarifying documentation or refusal documentation was requested, but not provided. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Nurse?Program specialist.
Individual continuously refuses a Pap test. The last time individual went to the OB?GYN she literally kicked the nurse when she attempted to perform a PAP test. |
05/30/2022
| Implemented |
| 6400.141(c)(14) | Individual #1 3/4/22 physical did not include information pertinent to diagnosis in case of emergency; that field was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | CEO/Program Specialist
Form has been updated by PCP to include information pertinent to diagnosis in case of emergency. |
04/22/2022
| Implemented |
| 6400.181(e)(11) | Individual #1 file did not contain a psychological evaluation, as it was not provided. | The assessment must include the following information: Psychological evaluations, if applicable. | Program specialist is responsible for this POC
An evaluation was requested and received from individuals Provider. Copy of Evaluation is currently on file |
03/31/2022
| Implemented |
| 6400.50(a) | A record of attendees was not kept for Individual #1 9/10/21 or 10/7/21 fire safety trainings, as it was not provided. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | Program specialist is responsible for this POC
A record of attendees has been produced for individual #1 10/07/21 fire safety trainings |
04/22/2022
| Implemented |
| 6400.165(g) | Individual #1 has not had reviews of their psychotropic medications, as records of those reviews were not provided. | 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. | Program specialist would be responsible for this POC
Individual does have reviews but communication is typically via phone calls versus Emails for other Residents. We have subsequently requested for documentation and notes on reviews from the Provider |
04/30/2022
| Implemented |
| 6400.196(a) | Staff who are responsible for implementing the restrictive procedures in Individual #1 plan have not been trained in those procedures, as clear documentation was not provided. | A staff person who implements or manages a behavior support component of an individual plan shall be trained in the use of the specific techniques or procedures that are used. | Program specialist is responsible for this POC
The Provider did train staff on the restrictive procedure for the individual but the signin sheet was not available at the time of inspection.( ) the individuals BC of over 10 years did provide an in house training and monthly zoom trainings. The agency has retrieved the signin and placed it in the individuals file. |
04/08/2022
| Implemented |
| 6400.213(1)(i) | Individual #1 file does not contain a record of their race or eye color. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Program Specialist
Record of Eye color and race has been updated and included in the program book. Additionally we have reviewed all the program books to ensure that individual does have this included. |
04/08/2022
| Implemented |