| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self-assessment of the home was started on 10/19/2024; however, no end date was documented on the self-assessment form. Compliance with this regulation could not be measured. Additionally, the agency's certificate of compliance expires on 1/6/2025; therefore, if the self-assessment was started on 10/19/2024, it could not have been completed within 3 to 6 months prior to the expiration of the certificate of compliance. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| The Self-Assessment was completed 3-6 months prior to inspection. However, we forgot to provide the Self-Assessment at inspection. |
10/31/2024
| Implemented |
| 6400.106 | The furnace was inspected and cleaned by a professional furnace cleaning company on 7/13/2023 and 10/22/2024. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| EYP will ensure that the Furnace inspection and cleaned by a professional furnace cleaning company on an annual basis. |
11/01/2024
| Implemented |
| 6400.141(c)(3) | Individual #2's physical examination, completed 8/5/2024, did not contain the individual's immunization history to include the most recent tetanus vaccination. [Repeat violation: 11/8/2023 et al] | 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. | I discovered that I had Individual¿s #2¿s current Immunization Records on the desk. I forgot to place the copy in his binder. Program Specialist will ensure that individuals current Immunization records are located in their binder so it is available upon request. |
10/30/2024
| Implemented |
| 6400.181(c) | Individual #1's initial assessment, completed 9/25/2024, stated that the information was based on "conversations and ISP data and recommendations" rather than assessment instruments, interviews, progress notes, and observations.
Individual #2's initial assessment, completed 10/2/2024, stated that the information was based on "conversations and ISP data and recommendations" rather than assessment instruments, interviews, progress notes, and observations. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | Program Specialist will ensure that individuals¿ assessments are based on assessment instruments, interviews, progress notes and observations. |
10/31/2024
| Implemented |
| 6400.181(d) | Individual #2's initial assessment, completed 10/2/2024, was not signed and dated by the program specialist. [Repeat violation: 11/8/2023 et al] | The program specialist shall sign and date the assessment. | Program Specialist will ensure that the individuals assessment is dated and signs the assessment. |
10/30/2024
| Implemented |
| 6400.52(a)(1) | Direct Service Worker #1 only participated in 23.5 training hours over the course of the 1/1/2023 through 12/31/2023 training year. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | Direct Service Worker #1 completed more than 23.5 training hours. However, I did not include all the trainings that were completed on the Training Transcripts. EYP Administrative Team will be more organized and all the staff trainings will be placed in their training file and include that training on their Training Transcripts. |
10/31/2024
| Implemented |
| 6400.169(d) | According to interviews with agency staff, Direct Service Worker #2 does administer medication. A record of the staff's medication administration trainings could not be provided by the agency. | A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed. | Direct Service Worker #2 completed Medication Administration Training. However, I misplaced their Medication Administration documents. EYP Administrative Team will be more organized and place Medication Administration documents in their staff¿s training file and include that training on their Training Transcripts. |
10/31/2024
| Implemented |
| 6400.181(f) | Individual #2's initial assessment was completed on 10/2/2024. There was no documentation on file that the assessment was disseminated to the plan team upon completion. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Individual #2 `s Initial Assessment was distributed to the team, I misplaced the emails that state that I distributed the assessment. Program Specialist will store the emails that state the I distributed the assessment in a binder, so the documents can be retrieved when requested. |
10/31/2024
| Implemented |