| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | Ceiling in the kitchen had substantial water damage and was patched over with a board.
Agency said that this was reported to the complex and that the complex put the board up, requested documentation/work order but it was not provided. | Floors, walls, ceilings and other surfaces shall be in good repair. | We contacted the apartment complex Sherwood Crossing to report the damage. And was given a work order number 4402333. They came and covered the damage with a patched. According to the manager, they are short staff but trying. |
| Implemented |
| 6400.68(b) | Water temperature in the home was 128.2. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The plan of correction is installed a "Shower Temperature control valve" to adjust the hot water temperatures in the home. |
09/22/2022
| Implemented |
| 6400.111(f) | There were no inspection tags on the fire extinguishers in the home. All were inspected by agency staff. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | The plan of correction is to contact Emergency Response for yearly inspection and updated tag |
09/22/2022
| Implemented |
| 6400.113(a) | There was no current fire safety training provided for individual#1. | 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 fire safety training was completed on 4/5/2021 by the individual |
09/22/2022
| Implemented |
| 6400.141(a) | No physical exam provided for individual#1. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual 1 completed his physical exam on 11/ 10/2021 with Dr. Yana Saknovsy. |
09/22/2022
| Implemented |
| 6400.142(a) | Agency did not provide a completed dental exam for individual#1. | 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. | Individual#1 had scheduled dental appointment with Special Touch, Dr. Bresler on:
5/26/21, 6/30/21, 7/4/21, 9/8/21, 11/3/21, 12/8/21 and 6/15/2022. He refused to attend the last appointment and we rescheduled for 1/25/2023 |
09/22/2022
| Implemented |
| 6400.151(a) | There was no physical exam found in record for staff member #1. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | The staff completed physical exam, but the doctor did not complete the form but printed the report and attach to physical form. |
09/22/2022
| Implemented |
| 6400.181(a) | The assessment provided for individual#1 was dated 10/12/21. There was no previous assessment provided, therefore there is no documentation showing that the assessment was completed on an annual basis. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Individual # 1 assessment was completed on 06/21/2021 60 days after he moved into home. |
09/22/2022
| Implemented |
| 6400.181(d) | There was no documentation showing who attended individual#1 most recent ISP meeting. | The program specialist shall sign and date the assessment. | The plan of correction after scheduled ISP meeting is make sure a copy of the sign-in sheet is left at the agency. In this case, after the scheduled ISP I contacted the SC for a copy but got no response and called the manager but no response. I was just informed the SC no longer work at the agency. |
09/22/2022
| Implemented |
| 6400.181(e)(10) | No lifetime medical was provided as part of individual#1 annual assessment. | The assessment must include the following information: A lifetime medical history. | Individual#1 annual assessment and lifetime medical history was completed on 12/01/2021. |
09/22/2022
| Implemented |
| 6400.217 | There was no signed consent form on file for individual#1. | 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.
| The individual#1 has no family nor guardianship to provide consent. |
09/22/2022
| Implemented |
| 6400.24 | There was no FBI background check found in the record for staff member #2 or documentation of residence 2 years prior to employment. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | The plan is to provide new employees with FBI form for background check. |
09/22/2022
| Implemented |
| 6400.34(a) | There was no signed individual rights statement provided for individual#1. | 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. | We have signed individual rights statement in the record file at the office. |
09/22/2022
| Implemented |
| 6400.46(b) | There was no record of fire safety training for staff member #1. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | The individual fire safety training for staff member # 1 was completed by an independency contractor. |
09/22/2022
| Implemented |
| 6400.165(f) | There was no 3 month psychotropic medication reviews provided for individual#1. | 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. | Individual#1 has ongoing counseling through Zoom with Dr. Alhomsi from Merakey. He met with Dr. Alhomsi on 03/24/22, 7/28/22 and scheduled for another 3 months review on 10/28/2022 |
09/22/2022
| Implemented |
| 6400.183(c) | No documentation provided as to when individual#1's 10/12/21 assessment was sent to members of the team. | The list of persons who participated in the individual plan meeting shall be kept. | The plan of correction is sent assessment to members of individual's treatment team before the next ISP meeting. |
09/22/2022
| Implemented |
| 6400.213(1)(i) | The following information was not found in the file of individual#1.
Admission date, Social Security Number, Hair Color, Eye Color, Identifying Marks, Next of Kin, Current Dated Photograph. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | We are in compliance please find copy. |
10/18/2021
| Implemented |