| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.34(a) | Individual #1 was informed of the individual rights, however all rights were not included. Missing rights included: 32e; 32g; 32i; 32q; 32r2; 32r3; 32r4; 32r5. Right 32l stated: "the individual has the right to receive visitors at reasonable hours" Individual #1 was informed of this right, however the language is not consistent with chapter 6400.32l- "An individual has the right to receive scheduled and unscheduled visitors, and to communicate and meet privately with whom the individual chooses, at any time." Individual right 32n in the provider policy states, "an individual has the right to reasonable access to a telephone in the building which he or she resides and to make private calls with assistance when necessary." The language is not consistent with chapter 6400.32n-An individual has the right to unrestricted and private access to telecommunications. | 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. | The agency has updated the language on the individual rights document in accordance with Chapter 6400.32l concerning individual rights and added the following rights: 32e; 32g; 32i; 32q; 32r2; 32r3; 32r4; 32r5. The agency's documentation on individual rights has been updated and forwarded for your review. |
07/22/2024
| Implemented |
| 6400.46(b) | Staff #1 did complete annual fire safety training late. Staff #1 completed fire safety on 4/30/22 and did not complete it again until 6/16/23. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | staff #1 and all other staff members are trained 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms; and notification of the local fire department as soon as possible after a fire is discovered. |
07/22/2024
| Implemented |
| 6400.165(g) | Individual #1 was admitted to the program on 11/4/23. Individual #1 is prescribed Risperidone to treat symptoms of psychiatric illness. Individual #1 did not have reviews of this medication at least every three months. | 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 provider agency will ensure that individual #1 is seen by a licensed practitioner who is prescribing all psychotropic medications to treat symptoms of psychiatric illness at least every three months. A psychotropic medication review document will be completed to indicate the reason for prescribing the medication, the need to continue the medication, and the necessary dosage. |
07/22/2024
| Implemented |