| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | On 10/29/2024, the agency's self-assessment of the home, end dated 10/4/2024, did not address the following 6400 regulations, as they were left blank: 11, 13, 14a, 14b, 15b, 15c, 21e-25d under General Requirements; 42 through and including 52c6 under Staffing; 151a through and including 152c under Staff Health, 195d and 209 under Plan Development/Process/Content; 189 through and including 190c under Day Services/Recreational and Social Activities; 207(4), 207(5), 208a, 208b, 207(1), and 207(2) under Restrictive Procedures; 211a through and including 217 under Individuals Records; 231 through and including 245d under 9 or More Individuals; 251a and 251b under Emergency Placement; 261a through and including 263 under Respite Care; 271(1) through and including 275 under Semi-Independent Living. | 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 Director of Programs will complete the self assessment between June and September which is 3-6 months prior to the expiration of the certificate of compliance. The self - assessment will be completed on the approved ODP form and will measure compliance / non compliance. This agency will no longer utilize the self - assessment form created for agency use only. |
11/01/2024
| Implemented |
| 6400.141(c)(1) | Individual #1's physical examination, completed on 11/17/2023, did not include a review of medical history. | The physical examination shall include: A review of previous medical history. | The Program Specialist will ensure that the individual form is completed in its entirety prior to uploading forms to the agency shared drive. Any forms that are not completed in its entirety will be returned to the physician for review. This will be the responsibility of the Program Specialist to ensure compliance. |
11/01/2024
| Implemented |
| 6400.141(c)(3) | Individual #1's physical examination, completed on 11/17/2023, did not address immunizations. | 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. | The Program Specialist will ensure that the individual form is completed in its entirety prior to uploading forms to the agency shared drive. Any forms that are not completed in its entirety will be returned to the physician for review. This will be the responsibility of the Program Specialist to ensure compliance. |
11/01/2024
| Implemented |
| 6400.181(e)(10) | Individual #1's assessment completed on 2/19/2024 did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | The program specialist was retrained and reviewed the assessment and components of the reports by the director of program services on 11/8/24 |
11/08/2024
| Implemented |
| 6400.181(e)(12) | Individual #1's assessment completed on 2/19/2024 did not include recommendations for specific areas of training, programing and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The program specialist will ensure that the assessment drives the ISP. The program specialist will ensure that the assessment information is accurately captured in the individual ISP. The Program Specialist will email the Supports Coordinator to update the ISP accordingly. The program specialist was trained on 11/1/24 by the Director of Programs - to ensure the understanding that the assessment drives the ISP. The Program Specialist was re-trained on the components of the ISP and assessment. |
11/01/2024
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medications to treat the symptoms of a diagnosed psychiatric illness. Individual #1 had a psychiatric medication review completed on 5/13/2024 and then again on 8/26/2024. this exceeds the at least every 3-month requirement. | 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. | The program specialist will utilize the medical regulatory form created by this agency to track upcoming appointment and to ensure compliance is met. The program specialist reviewed the form and retrained on use on 11/8/24, by the director of programs. |
11/08/2024
| Implemented |
| 6400.166(a)(11) | Individual #1 is prescribed Refresh Tears 0.5% Drops with directions to pace 1 drop in each eye 4 times a day as needed. The October 2024 Medication Administration Record for Individual #1's prescribed Refresh Tears 0.5% was missing the reason for prescribing. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | The MAR was corrected to add the reason for the prescribed medication on 10/31/24. |
11/10/2024
| Implemented |
| 6400.182(c) | Individual #1's individual support plan last updated 10/22/2024 states the individual is able to regulate their bath water temperature with physical assistance. Individual #1's assessment completed on 2/19/2024 states the individual is able to temper their own water independently with no prompts. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The program specialist will ensure that the assessment drives the ISP. The program specialist will ensure that the assessment information is accurately captured in the individual ISP. The Program Specialist will email the Supports Coordinator to update the ISP accordingly. The program specialist was trained on 11/1/24 by the Director of Programs - to ensure the understanding that the assessment drives the ISP. The Program Specialist was re-trained on the components of the ISP and assessment. |
11/22/2024
| Implemented |
| 6400.213(1)(i) | 213(1)i - Individual #1's record did not include the date of admission.
213(1)iii - Individual #1's record did not include eye color or identifying marks. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | The Program Specialist was retrained on the individual face sheet. The Program Specialist will complete all components of the face sheet during the admissions process. The Director of Programs will complete a final review of all intake admissions forms to ensure compliance. |
11/01/2024
| Implemented |