| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | A partial 6400 Self-Assessment, dated 4-7-24, contained the following areas that were left incomplete; Staffing, 50b-51a6, 44c1-44c3, Fire safety 110e, were left blank [Repeat violation 7/18/23, et. al.]. | 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.
| On July 27, 2024, The CEO trained the Residential Coordinator on the new Department's licensing inspection instrument, how to use it, and when it needs to be reassessed annually. |
08/06/2024
| Implemented |
| 6400.112(h) | On April 1, 2024, at 3:30 PM a fire drill was conducted. The designated meeting place was left blank on the fire drill record. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | On July 12 the CEO reeducated the Residential Coordinator about the safety of fire drills for all of our individuals and staff, it is important that everyone know where each designated meeting place is in case of a real fire. |
08/06/2024
| Implemented |
| 6400.214(b) | Individual #1's most current assessment was not located in the home. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| On July 17, 2024, The CEO Educated the Program Specialist and Residential Coordinator to ensure that all sites will have current hard copy records in the residential homes. |
08/07/2024
| Implemented |
| 6400.24 | On 7/10/24 Individual #1's ledger was deducted $40.00 on April 1, 2024 and $10.00 on April 20-2024 for laundry. Laundry is required to be included in the individual's room and board cost. Please reference 6100.484(d)(vii). | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | On July 15, 2024, The CEO Educated the Residential Coordinator · on all aspects of the Room & Board fees, to ensure that any money spent by the individuals are not being used for already allotted purposes such as Room & Board fees. |
08/07/2024
| Implemented |
| 6400.165(b) | On 7/10/24 at 10:28am, the following was observed: Individual is prescribed Retin-A Gel, but the medication was absent from the medication box. Staff did document discontinued on the MAR on 7/10/24. There was no discontinue order on site written by a physician. It was documented that individual #1 did receive the medication, each day to include the evening dose. A discontinue order written by the prescribing physician was requested by the agency at exit but has not been provided. | A prescription order shall be kept current. | On July 17, 2024, The CEO Educated the Program Specialist and residential coordinator on the importance of discontinuing medications and remove from the MAR and out of the site to prevent any medication errors that could be a result of an injury to the client. |
08/07/2024
| Implemented |