| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.70 | The home did not have a telephone with a outside line. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| LSHS has made available an operable, noncoin-operated telephone that is easily accessible to individuals and staff personnel. This phone is place in an area of the home that is accessible to the individual with emergency numbers clearly posted to be used at the convenience of the individual. |
10/26/2022
| Implemented |
| 6400.77(b) | The first aid kit did not contain a thermometer. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | LSHS have purchased and placed in the first aid kit at this home, to be used if the individual being served in this home is likely to need the use of the thermometer. |
10/27/2022
| Implemented |
| 6400.112(d) | All fire drills extended past 2.5 minutes must be documented and re-tested to ensure consumers can safely evacuate.
11/8/21, 12/15/21, 1/17/22, 2/1/22, 3/15/22, 4/13/22, 5/12/22, 6/8/22,7/8/22-3 mins long-no new drills taken | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | LSHS program manager and staff have received in-service training for implementing fire drills correctly to remain compliance with 6400.112(d) regulation. |
10/26/2022
| Implemented |
| 6400.113(a) | The fire safety training for Individual #3 was completed on 11/15/21, which is more than one month after his admission. Fire safety training is to be completed upon initial admission. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually 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 and smoking safety procedures if individuals smoke at the home. | The fire safety training for individuals#3 on 11/15/21, which is more than a month after his admission. LSHS program manager and program specialist has completed a general fire safety training with the indivieual#3. |
10/26/2022
| Implemented |
| 6400.141(c)(6) | There is no completed TB test. A doctor's note shows that a TB test was done on 1/19/22, and that the individual must return on 1/21/22 to have results read, but there is no record that this was done. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | The LSHS program manager has prearranged an appointment for the individual to retake his TB test, and we will ensure that the individual returns to have the test read. |
10/24/2022
| Implemented |
| 6400.181(e)(10) | There is no lifetime medical history in the file. | The assessment must include the following information: A lifetime medical history. | LSHS program specialist received in-service training regarding implementing all individuals' lifetime medical history and ensuring that the PC file and secure lifetime medical history in all individuals' medical files. |
10/26/2022
| Implemented |
| 6400.217 | There are no written consents in the file. (this is required for the release of information, including photographs) | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| The LSHS program specialist received in-service training regarding implementing and ensuring that all written consents, such as the release of information, are secure in all individuals' files. |
10/26/2022
| Implemented |
| 6400.34(b) | There is no signed copy of rights for Ind. #3 | The home shall keep a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights. | The LSHS program specialist received in-service training regarding implementing and ensuring that all contents, such as a copy of the rights of the individuals, are secure in all individuals' files. |
10/26/2022
| Implemented |
| 6400.165(g) | There were no psychotropic medication reviews for this individual #3. | 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. | LSHS has trained all employees to complete all individual psych/90-day meds reviews and ensure that the program specialist will document the appointments and make them available for review. |
10/26/2022
| Implemented |
| 6400.181(f) | There is no letter indicating that the assessment was sent to the individual #3 plan team 30 days prior the ISP meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The LSHS program specialist received in-service training regarding implementing and ensuring a cover letter accompanied the assessment when sent to the individual #3 plan team 30 days before the ISP meeting. |
10/26/2022
| Implemented |
| 6400.183(c) | The ISP meeting sign-in sheets were not found in the file. | The list of persons who participated in the individual plan meeting shall be kept. | The LSHS program specialist received in-service training regarding having a sign-in sheet for all ISP meetings, and the PS will have the sigh-in sheet file in the individuals' file. |
10/26/2022
| Implemented |
| 6400.213(1)(i) | There are several discrepancies in the contents of the file. Ind. #3 height and weight on the face sheet are 5' tall, 178 lbs. However, on the physical, his height and weight are 5'7", 300 lbs. Ind. #3 physical states that his vision is normal, however there are several mentions of him needing prescription glasses throughout his record. Ind. #3 DOA on the face sheet is 5/17/22, however his actual DOA is 10/5/21. Finally, Ind. #3 DOB is incorrect on his face sheet (9/19/96), when it's actually 1/19/96. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | The program specialist made the necessary correction to all content on the individual's factsheet. |
10/26/2022
| Implemented |