| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency's Certificate of Compliance expiration date was 8/19/2022. The agency completed the self-assessment of the home on 11/28/2022. | 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.
| Self-assessments were completed, however not within a timely manner. CEO and Program Specialist will complete future self-assessments within the required timeframe of 3 to 6 months prior to expiration date of the certificate of compliance. CEO and Program Specialist will complete all self-assessments by 5/19/23 and will begin self-assessments no later than 3/1/23 to measure compliance with applicable regulations and correct any identified deficiencies. Violations will be identified, and written summaries of corrective actions taken will be documented. |
03/01/2023
| Implemented |
| 6400.15(c) | Violations were identified by marking the "V" on the self-assessment; however, the agency did not identify the violations and complete a written summary of corrections made. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| Self-assessments were completed, however not within a timely manner. CEO and Program Specialist will complete future self-assessments within the required timeframe of 3 to 6 months prior to expiration date of the certificate of compliance. CEO and Program Specialist will complete all self-assessments by 5/19/23 and will begin self-assessments no later than 3/1/23 to measure compliance with applicable regulations and correct any identified deficiencies. Violations will be identified, and written summaries of corrective actions taken will be documented. |
03/01/2023
| Implemented |
| 6400.141(c)(4) | Individual #1's vision screening was completed on 7/1/21, and then again on 8/3/22. Individual #1's hearing screening was completed on 1/26/21, and then again on 2/15/22. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Vision screening to be scheduled immediately along with physical examination due by 2//16/23 and TB screening. CEO and program specialist will conduct audit of all individuals' files for compliance purposes. Any issues/noncompliance identified during the audit will be immediately corrected. CEO will develop a checklist for continued monthly monitoring by CEO and program specialist of all individual files in order to maintain compliance in the future. All staff, especially house managers, will be trained on the importance of completing all areas of medical records/documentation at the time of examination. |
03/01/2023
| Implemented |
| 6400.141(c)(7) | Individual #1 had a gynecological exam on 6/28/21, and then again on 8/1/22. | 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. | CEO will develop checklist for monthly audit by Program Specialist of all individuals' files. CEO will then monitor for compliance and that checklists are completed monthly to ensure regulatory compliance with all annual requirements. House managers will be provided with list of annul date requirements for compliance purposes. HMs will be responsible for scheduling all appointments and will be verified/confirmed by Program specialist during monthly audit. Any concerns will be addressed immediately by PS and HM. |
03/01/2023
| Implemented |
| 6400.142(a) | Individual #1 had a dental examination on 6/8/21, and then again on 8/17/22. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | CEO will develop checklist for monthly audit by Program Specialist of all individuals' files. CEO will then monitor for compliance and that checklists are completed monthly to ensure regulatory compliance with all annual requirements. House managers will be provided with list of annul date requirements for compliance purposes. HMs will be responsible for scheduling all appointments and will be verified/confirmed by Program specialist during monthly audit. Any concerns will be addressed immediately by PS and HM. |
03/01/2023
| Implemented |
| 6400.181(f) | The program specialist provided Individual #1's annual assessment, completed 2/2/22 to the invidual plan team members on 2/2/22 for an individual plan meeting on 2/14/22. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | CEO will develop and implement a checklist for Program Specialist to conduct monthly audit of all individuals' assessments to ensure they are completed and submitted to team members in a timely manner and within regulatory timeframes. Program Specialist to review applicable regulations for future compliance. |
03/01/2023
| Implemented |