| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | A self-assessment was not completed for this home. | 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.
| Completed self assessments will be sent to Department of licensing by end of work day April 5, 2024. |
04/05/2024
| Implemented |
| 6400.64(a) | The cabinets above the kitchen stovetop were coated in a shiny, translucent substance that was tacky to the touch---this substance was consistent in appearance and texture with the residue of evaporated cooking grease or oil. | Clean and sanitary conditions shall be maintained in the home. | All cabinets and ranges were cleaned with a degreaser in all homes. This chore was added to the chore check list. |
04/01/2024
| Implemented |
| 6400.72(a) | One of the two windows in Individual #1's bedroom lacked a screen. At the time of inspection, this window was found to be cracked open approximately 1 inch. As there was no screen within the home that could be fit within the window while in use, this window was incapable of being securely screened. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Apartment Management was notified in regard of screen missing. All residential homes were checked for missing screens. . |
04/01/2024
| Implemented |
| 6400.141(c)(10) | Individual #1's Physical Examination, dated 02/28/2024, does not specify whether or not the individual is free from communicable diseases. There is a line item asking, "Is the person free of communicable disease?" on the physical form, with corresponding yes/no checkboxes and a line to write additional information. Neither the yes nor the no checkbox is checked off and the line is blank. This information is not found elsewhere on the form. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | Program Specialist has reviewed all clients physical exam for disclosure of "free for communicable Disease". |
04/01/2024
| Implemented |
| 6400.165(g) | Per physician encounter forms within Individual #1's Individual Record, the psychiatric visits occurring during the period of review did not include the reason for prescribing each of the individual's psychotropic medications, the need to continue each of these medications, and the necessary dosage for each of these medications. | 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. | Program specialist reviewed the individuals files for accuracy. |
04/01/2024
| Implemented |
| 6400.195(b) | Individual #1 has a restrictive procedure in place to lock sharp objects within the home. There is a record of a Human Rights Team (HRT) meeting at which this restrictive procedure was discussed that is dated 01/19/2023. There is no record of six-month reviews occuring for this restrictive procedure plan. | The behavior support component of the individual plan shall be reviewed and revised as necessary by the human rights team, according to the time frame established by the team, not to exceed 6 months between reviews. | Program Specialist will reach out to follow up in regard to the review to ensure all information. |
04/01/2024
| Implemented |