| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | Individual #2's ISP indicates that the individual is not able to manage any amount of money. Individual #2 receives $30 a week placed on a debit card and occasional cash from the individual's parent. There is no financial record maintained of the amount(s) of money received or spent by the individual. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | on 3/1/22 A money ledger has been implemented to track individual spending. A financial policy has been implemented for staff to read, sign and follow it when caring for the individual. ( see attached money ledger, and financial policy training emailed to Kristen) |
03/01/2022
| Implemented |
| 6400.64(a) | The shower head in Individual #2's bathroom was covered with a significant layer of limescale and mildew. | Clean and sanitary conditions shall be maintained in the home. | On 3/5/22 staff was trained on how to keep the shower head clean at all times. shower head is now cleaned. ( see attached photo of cleaned shower head emailed to Kristen) |
03/05/2022
| Implemented |
| 6400.64(f) | There was a bag of garbage on the back porch of the home not in a trash receptacle. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | On 3/4/22 staff was trained on how to keep the outside of the house and back porch free from garbage bags. the back porch of the house was cleaned and the bag of garbage was removed ( see attached photo of clean back porch emailed to Kristen) |
03/04/2022
| Implemented |
| 6400.66 | There is no lighting going down the basement steps. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| On 3/4/22. The basement steps lighting was placed. ( see attached photo of basement step light emailed to Kristen) |
03/04/2022
| Implemented |
| 6400.67(a) | There is a hole in the concrete of the home in the front of the basement. The hole opens to outside of the home.
There is no door knob on the door leading from one room of the basement to the other. The knob is missing.
The screen on the screen door off of the kitchen is ripped and not in good repair. | Floors, walls, ceilings and other surfaces shall be in good repair. | on 3/4/22 the hole on the concrete of the home Infront of the basement was repaired ( see attached photo of the the repaired hole emailed to Kristen).
KCF: Confirmed the doors have also been repaired. |
03/04/2022
| Implemented |
| 6400.141(c)(14) | Individual #2's annual physical examination dated 2/8/22 did not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | On 2/7/22 medical evaluation was done with medical information pertinent to diagnosis. The program specialist will remember to include medical evaluation to sent document. ( see attached medical evaluation emailed to Kristen) |
03/01/2022
| Implemented |
| 6400.181(e)(13)(i) | Individual #2's annual assessment dated 10/4/21 did not address progress and growth in the following areas: Health | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| On 3/4/22 assessment was corrected. ( see attached corrected assessment emailed to Kristen) |
03/04/2022
| Implemented |
| 6400.181(e)(13)(iv) | Individual #2's annual assessment dated 10/4/21 did not address progress and growth in the following area: Personal Adjustment | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | On 3/4/22 assessment was corrected. the individual has adjusted well and able to maintain a healthy lifestyle by portion control and exercise. twice a week. ( see attached corrected assessment emailed to Kristen) |
03/04/2022
| Implemented |
| 6400.181(e)(13)(v) | Individual #2's annual assessment dated 10/4/21 did not address progress and growth in the following areas: Socialization | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | on 3/4/22 assessment was corrected . Individual has made a lot of progress in socialization she now has a lot of friend from her day program that she called and checked on them . she interact very well with all her staff. ( see attached corrected assessment emailed to Kristen) |
03/04/2022
| Implemented |
| 6400.181(e)(13)(vi) | Individual #2's annual assessment dated 10/4/21 did not address progress and growth in the following areas: Recreation | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | on 3/4/22 assessment was corrected. Individual currently is maintaining friendship in a stable bases and familiar setting like her day program. she will participate in social activities with encouragement from her staff . ( see attached corrected assessment emailed to Kristen) |
03/04/2022
| Implemented |
| 6400.181(e)(13)(vii) | Individual #2's annual assessment dated 10/4/21 did not address progress and growth in the following areas : Financial Independence | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| on 3/4/22 assessment was corrected. Individual has made progress in holding money up to $5 cash . she takes a $1 to day program and can buy candy independently. ( see attached corrected assessment emailed to Kristen) |
03/04/2022
| Implemented |
| 6400.181(e)(13)(viii) | Individual #2's annual assessment dated 10/4/21 did not address progress and growth in the following areas: Managing Personal Property | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | on 3/4/22 assessment was corrected. Individual is currently able to mange her personal property. she doesn't get involved in property destruction. ( see attachment corrected assessment emailed to Kristen) |
03/04/2022
| Implemented |
| 6400.181(e)(14) | Individual #2's annual assessment dated 10/4/21 does not address the individual's ability to swim. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | On 3/4/22 assessment was corrected. currently individual is able to swim independently.( see attached assessment correction emailed to Kristen) |
03/04/2022
| Implemented |
| 6400.34(a) | Individual #2 was informed of individual #2's rights on 2/11/22. Individual #2 was previously informed of individual #2's rights on 1/15/21. Individual #2 was late being informed of the individuals rights. | 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. | On 3/1/22 program specialist was retrained. ( see attached new created check list emailed to kristen) |
03/01/2022
| Implemented |
| 6400.163(h) | Individual #2 was prescribed Triamcinolone 0.5% ointment, apply top to affected areas 2x daily as needed for up to two weeks. This medication was prescribed on 8/12/21 for up to two weeks. The medication was not discontinued after two weeks, was not disposed of properly and remained listed on the Medication Administration Record. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | On 3/3/22 staff re-trained. ( see attached training emailed to Kristen) |
03/03/2022
| Implemented |
| 6400.165(b) | Individual #2 is prescribed Cetaphil Daily Facial Lotion. This medication was last filled on 2/20/20 and the bottle expired in 10/21. This prescription was not kept current. | A prescription order shall be kept current. | on 3/3/22 staff retrained. ( see attached training and memo emailed to Kristen) |
03/03/2022
| Implemented |
| 6400.165(g) | Individual #2 is prescribed psychotropic medications and had three-month medication reviews. completed on 4/26/21, 6/18/21, 7/16/21, 8/25/21 and 10/13/21. The medication review documentation did not include the reason for prescribing the medication and the necessary dosage of the medication. | 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. | on 3/1/22 program Director wrote a letter to the physician notifying him on the need to proper document the reason and dosage of medication prescribed. ( see attached letter emailed to Kristen) |
03/01/2022
| Implemented |
| 6400.166(b) | Individual #2 is prescribed Cetaphil Daily Facial Lotion, apply to face 2 times a day at 8AM and 8PM. This medication was not documented on the Medication Administration Record. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | on 3/3/22 program director wrote a letter to the pharmacy notifying pharmacy to doubt check MAR and make sure all medication are there before sending it. ( see attached letter to Pharmacy emailed to Kristen) |
03/03/2022
| Implemented |