| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(b) | There was a large build-up of lint in the dryer, posing a fire hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Support staff failed to empty the lint trap after using the dryer.
On 5/11/23 the support staff immediately cleaned the dryer lint at the time of the inspection. The program manager placed a sign in the dryer to remind staff to clean the dryer lint trap after each use. |
05/11/2023
| Implemented |
| 6400.113(a) | Individual #1 was not trained in fire safety at the time of admission. | 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. | The program manager to complete a general fire safety training upon admission for both individual #1 and individual #12.
On 5/30/23, Individual #1 and #2 were both trained in general fire safety and smoking safety procedures. |
05/30/2023
| Implemented |
| 6400.217 | Individual #1 did not have a signed release of information in their record. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| Individual #1 signed released of information was improperly filed away in their main file record binder.
On 5/12/23, the program manager completed an audit of individual #1 main file binder. The completed and signed release of information form for individual #1 was filed correctly in their main file. |
05/12/2022
| Implemented |
| 6400.34(b) | Individual #1 did not have a signed copy of their rights in their file indicating that they were informed of their individual rights at admission. | The home shall keep a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights. | Individual #1 signed released of information was improperly filed away in their main file record binder.
On 5/12/23, the program manager completed an audit of individual #1 main file binder. The completed and signed individual rights attestation form for individual #1 was filed correctly in their main file. |
12/12/2023
| Implemented |
| 6400.166(a)(4) | Individual #1's medication administration record (MAR) was updated on or about 5/8/23, but not all medications were transferred over from the previous MAR. Their prescribed PRN medication diphenhydram 25mg. medication was in the medication box but not on the MAR that is currently in use. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | Support staff failed to transcribe all medications to include the PRNs for individual #1 onto the medication record.
On 5/11/23, individual #1 diphenhydram 25mg medication was immediately transcribed on the medication record. Staff was re-educate on transcribing all medications to include PRNs onto the medication record. |
05/11/2023
| Implemented |
| 6400.166(a)(13) | Individual #1s 8AM administration of prescribed medication omeprazole was not signed for on their 5/11/23 medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | The program manager failed document the administration of individual #1 8am Omeprazole medication.
On 5/11/23, the program manager immediately signed off on administering individual #1's 8am medications. |
05/11/2023
| Implemented |
| 6400.193(a) | The property's knives were found locked up with the apartment's cleaning chemicals. Individual #1, the sole occupant, does not have a restrictive behavioral plan, and their ISP specifically indicates they are safe with knives. Restrictive procedures are being applied unnecessarily. | A restrictive procedure may not be used as retribution, for the convenience of staff persons, as a substitute for the program or in a way that interferes with the individual's developmental program. | The program manager assumed that all sharp objects had to be locked in the home therefore, the knives were placed in a locked container for safety.
On 5/11/23, the knives were placed back into the kitchen as there are no restrictive procedures for individual #1. |
05/11/2023
| Implemented |