| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Ind. #13 behavior support plan states that all chemicals should be locked away, but there was anti-bacterial soft-soap hand soap in the bathroom vanity with an active ingredient chemical of benzalkonium chloride. | Poisonous materials shall be kept locked or made inaccessible to individuals. | 1. This was corrected on site, the soap was removed and locked |
12/09/2022
| Implemented |
| 6400.68(b) | The water temperature in the bathroom measured 126.6 degrees Fahrenheit. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | 1. The agency sent a plumber to the home to immediately to assess the water heater and lower the temperature. |
12/09/2022
| Implemented |
| 6400.181(e)(6) | Ind. #13, 4/27/22 assessment states via the providers number system (5) that they are independent in safely using and avoiding poisonous materials, however the comments state that all poisons must be locked away for their safety. | 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. | 1. The ISP has been updated to state that individual #13 is not aware of safety items. |
12/09/2022
| Implemented |
| 6400.32(r) | Ind. #13-bedroom door had the locking mechanism missing from the doorknob. Staff believe he may have had a behavior and when the door was put back on this accidentally did not get put back on with the rest of the doorknob. This missing piece prevents the individual from locking their door, which they have the right to do, unless it is documented in a restrictive plan and approved by a human rights team. | An individual has the right to lock the individual's bedroom door. | ¿ Individual #13 has a signed locked declination form signed as of 7/8/22 |
12/09/2022
| Implemented |
| 6400.34(a) | Ind. #13 signed individual rights page is not dated, so unable to determine if it was completed at admission | 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. | After further review the rights page was located and the individual rights page was signed on 9/17/22 |
12/09/2022
| Implemented |
| 6400.165(g) | Ind. #13 takes prescribed psychotropic medications clonidine .1 mg, divalproex sodium 500 mg and risperidone .5 mg and 2 mg. Quarterly medication reviews have not been conducted. Medication reviews were conducted on 3/11/22 and 7/21/22, which is more than three months apart. | 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. | It is the responsibility of the Program Director to ensure that the medications reviews are scheduled every 3 months. |
12/09/2022
| Implemented |
| 6400.186 | Ind. #13, individual support plan states that all chemicals should be inaccessible as they have a history of ingesting these things including deodorant, however there were two speed stick deodorants and a crest premium plus toothpaste in Individuals bedroom closet. | The home shall implement the individual plan, including revisions. | This was corrected the deodorant and toothpaste were removed from the closet. |
12/09/2022
| Implemented |
| 6400.213(1)(i) | Ind. #13 record did not contain his admission date. The face sheet line where this would be captured was blank. His admission date was written in this line during the inspection. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | This was corrected at the time of inspection |
12/09/2022
| Implemented |
| 6400.213(1)(i) | Ind. #13 record did not include any identifying marks that they may have. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | This has been corrected the emergency sheet has been updated with the individuals identifying marks. |
12/09/2022
| Implemented |