| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(c) | The fire drill conducted on 2/2/23 did not include the time of day that the fire drill was completed as this section of the form was left blank. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | SOP is being developed for Team Leads & Program managers regarding Fire drill forms and administrative review requirements (Completed 7/31/23)
Training on the Fire Drill form itself, SOP, and the administrative review process will be completed by 8/15/23.
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08/15/2023
| Implemented |
| 6400.112(h) | The fire drill conducted on 8/13/22 did not indicate if all of the Individuals evacuate to a designated meeting place outside the home during each fire drill as this section of the form was left blank. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | SOP is being developed for Team Leads & Program managers regarding Fire drill forms and administrative review requirements (Completed 7/31/23)
Training on the Fire Drill form itself, SOP, and the administrative review process will be completed by 8/15/23. |
08/15/2023
| Implemented |
| 6400.142(f) | There was no record or documentation of a dental hygiene plan for Individual #1 | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | Client services called all dentists on record and received recommendations (8/1/23) |
08/15/2023
| Implemented |
| 6400.151(c)(2) | Tuberculin skin testing by Mantoux method with negative results every 2 years. Staff #1's date of hire is 2/6/23 and their Tuberculin skin testing by Mantoux method with negative results occurred on 4/7/23. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | New ADP workforce NOW contract will keep track of all HR requirements (Criminal Histories, Physicals, TB Tests) |
01/01/2023
| Implemented |
| 6400.181(e)(6) | Individual #1's assessment dated 1/27/2023 did not assess or address the individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | Poison Safety question was added retroactively to all 2022/2023 Annual Assessments. |
07/24/2023
| Implemented |
| 6400.32(r) | Individual #1's bedroom door lock was "coin key" lock, this type of lock does not provide the level of privacy and security of person and possessions as expected by the regulation. | An individual has the right to lock the individual's bedroom door. | Operations will make lock changes to all possible doors |
08/31/2023
| Implemented |
| 6400.165(g) | Individual #1 prescribed medication to treat symptoms of a psychiatric illness. Individual #1 had a 3-month psychiatric medication review on 3/28/23 and 6/27/23, and the form used for the visit did not include the necessary dosage of 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. | Medication lists will be attached to all psych notes for physician review and available when viewed in the scanned BOX paperwork (7/19/23 and ongoing)
Medical note updated to reflect Psychiatric med review of medications and the symptoms requiring ongoing treatment. |
07/21/2023
| Implemented |