| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(e)(1) | On 7/19/23, Individual #1's financial record was not up-to-date, as the ledger was found to be missing transactions, including funds received by and disbursements made to them for purchases. The agency provides assistance in maintaining Individual #1's finances, as their 5/17/23 assessment indicates the need for help in this skill domain. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. | The home shall maintain financial records including dates and amounts of deposit and withdrawl |
08/21/2023
| Implemented |
| 6400.22(e)(3) | On 7/19/23, Individual #1's financial record was missing a receipt for a purchase of $20 made on 6/29/23 at The Vape Store. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | A home shall have documentation with actual receipts of each purchase exceeding $15 |
08/21/2023
| Implemented |
| 6400.68(b) | On 7/19/23, the hot water temperature of the bathtub in the bathroom located in the bedroom hallway measured 135.5°F at 1:10 PM. [Repeated Violation---11/9/21, 10/4/22, et al] | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Hot water temp shall not exceed 120 degrees |
08/21/2023
| Implemented |
| 6400.82(e) | On 7/19/23, the bathtub in the bathroom located in the bedroom hallway was observed without a mat or non-slip surface. | Bathtubs and showers shall have a nonslip surface or mat. | Bathtubs and showers shall have a non slip surface |
08/21/2023
| Implemented |
| 6400.113(a) | Individual #1's admission date is 4/17/23. Their initial fire safety training was completed on 5/16/23. [Repeated Violation---10/4/22, et al] | 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 trained upon admission and annually thereafter |
08/21/2023
| Implemented |
| 6400.141(c)(1) | Individual #1's physical examination completed on 4/16/23 did not include their previous medical history. [Repeated Violation---10/4/22, et al] | The physical examination shall include: A review of previous medical history. | The physical exam shall have previous medical history |
08/21/2023
| Implemented |
| 6400.141(c)(3) | Individual #1's physical examination completed on 4/16/23 did not include a record of their immunizations. | 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 exam should include immunization |
08/21/2023
| Implemented |
| 6400.141(c)(6) | Individual #1's admission date is 4/17/23. Their record did not include any documentation of a completed tuberculosis test. [Repeated Violation---10/4/22, et al] | 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. | The physical exam shall have tb testing |
08/21/2023
| Implemented |
| 6400.141(c)(7) | Individual #1's date-of-birth is 4/16/05. On Individual #1's most recent gynecological examination completed on 5/3/22, the physician had deferred all subsequent examinations until they reach age 21 or whenever they become sexually active. Individual #1's 11/28/22 individual plan informs that they have a sexual history. | 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. | The physical exam shall include: gyne exam including a breast exam and pap test for women 18 years of age or older. |
08/21/2023
| Implemented |
| 6400.141(c)(12) | Individual #1's physical examination completed on 4/16/23 did not include their physical limitations. | The physical examination shall include: Physical limitations of the individual. | THe physical exam shall include physical limitations |
08/21/2023
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination completed on 4/16/23 did not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The physical exam shall have pertinent medical information and treatment in case of an emergency |
08/21/2023
| Implemented |
| 6400.181(e)(1) | Individual #1's assessment completed on 5/17/23 did not include their functional strengths, needs, and preferences. This section was left blank. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | The assessment shall have functional strengths needs and preference |
08/21/2023
| Implemented |
| 6400.181(e)(2) | Individual #1's assessment completed on 5/17/23 did not include their dislikes. This item was left blank. | The assessment must include the following information: The likes, dislikes and interest of the individual. | The assessment shall include likes dislikes and interest |
08/21/2023
| Implemented |
| 6400.181(e)(6) | Individual #1's assessment completed on 5/17/23 did not measure their ability to safely use or avoid poisonous materials. This item was marked with an "X," indicating that it does not apply. | The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | The assessment shall include ability to safely use or avoid poisonous materials |
08/21/2023
| Implemented |
| 6400.181(e)(9) | Individual #1's assessment completed on 5/17/23 did not address their functional and medical limitations. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | The assessment must include functional and medical limitations |
08/21/2023
| Implemented |
| 6400.181(e)(12) | Individual #1's assessment completed on 5/17/23 did not include recommendations for specific areas of training, programming, and services. This section was left bank. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The assessment shall have recommendations for specific areas of training programming and services |
08/21/2023
| Implemented |
| 6400.181(e)(14) | Individual #1's assessment completed on 5/17/23 did not measure their ability to swim. This item was marked with an "X," indicating that it does not apply. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | The assessment shall include progress over last 365 calendar days water safety and ability to swim |
08/21/2023
| Implemented |
| 6400.18(a)(8) | EIM Incident #: 9233651 for a behavioral health crisis involving law enforcement response was discovered on 6/16/23 at 11:30 AM and reported on 6/17/23 at 4:00 PM. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Law enforcement activity that occurs during the provision of a service or for which an individual is the subject of a law enforcement investigation that may lead to criminal charges against the individual.
| The home shall report the following incidents within 24 hours of discovery by a staff person or law enforcement |
08/21/2023
| Implemented |
| 6400.34(a) | Individual #1 was informed and explained their rights on 4/17/23. The rights document did not include the following: 6400.32c···the right to be free from exploitation and abandonment; 6400.32n···the right to unrestricted and private access to telecommunications; 6400.32r2···the right to limiting access to their bedroom except in a life-safety emergency or with their expressed permission; and 6400.32s···the right to having a key, access card, keypad code or other entry mechanism to lock and unlock an entrance door of the home. [Repeated Violation---10/4/22, et al] | 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 rights form shall be completed upon admission and annually thereafter |
08/21/2023
| Implemented |
| 6400.165(f) | Individual #1 is prescribed medication to treat symptoms of a diagnosed psychiatric illness. A written protocol to address their social, emotional, and environmental needs related to the symptoms of the psychiatric illness was not found as part of their individual plan or anywhere else in their record. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | Med is prescribed to treatment of diagnosed psych illness, there shall be a written protocol as part of the individual plan to address SEEP. |
08/21/2023
| Implemented |