| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | On 10/29/2024, the agency's self-assessment of the home, end dated 10/11/2024, did not address the following 6400 regulations, as they were left blank: 42 through and including 51b1 under Staffing; 67c, 72b under Physical Site; 145(3) under Individuals Health; 190a2, 190b, 190c under Day Services/Recreational and Social Activities. | 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.
| The Director of Programs will complete the self - assessment on the ODP approved agency form only. The self - assessment will be completed between June and September which is 3-6 months prior to the expiration of the certificate of compliance. Areas of non - compliance will be addressed by the Director of Programs. The Director of Programs was re -trained on the Self - Assessment forms approved by ODP. This is the only form that would be used to measure site and agency compliance. |
11/01/2024
| Implemented |
| 6400.101 | On 10/30/2024 at 10:40 AM, the door leading to the furnace room in Individual #1's bedroom has a lock on the door handle that when engaged, prevents the door handle from being moved. This creates a potential entrapment risk. [Repeat violation 11/14/24, et. al] | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The child proof lock has been removed from the door leading to the furnace on 10/31/24. |
10/31/2024
| Implemented |
| 6400.141(c)(11) | Individual #1's physical examination, conducted on 6/24/2024, did not include an assessment of the individual's medication regimen. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | The Program Specialist will ensure that the individual form is completed in its entirety prior to uploading forms to the agency shared drive.
The Program Specialist was re -trained on 11/1/24 on the agency physical forms. The program specialist reviewed all components of the forms that require completion from a physician. The program specialist will have annual review / training on documentation to ensure continued compliance. |
11/01/2024
| Implemented |
| 6400.141(c)(13) | Individual #1's physical examination, conducted on 6/24/2024, did not address allergies or contraindicated medications. | The physical examination shall include: Allergies or contraindicated medications. | The Program Specialist will ensure that the individual form is completed in its entirety prior to uploading forms to the agency shared drive.
The Program Specialist was re -trained on 11/1/24 on the agency physical forms. The program specialist reviewed all components of the forms that require completion from a physician. The program specialist will have annual review / training on documentation to ensure continued compliance. |
11/01/2024
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination, conducted on 6/24/2024, did not address medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The Program Specialist will ensure that the individual form is completed in its entirety prior to uploading forms to the agency shared drive.
The Program Specialist was re -trained on 11/1/24 on the agency physical forms. The program specialist reviewed all components of the forms that require completion from a physician. The program specialist will have annual review / training on documentation to ensure continued compliance. |
11/01/2024
| Implemented |
| 6400.181(e)(10) | Individual #1's assessment, completed on 8/22/2024, did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | The lifetime medical history read ( see attached) it was on a separate form. The life time medical history will no longer be included as an attachment . The forms have been revised to leave a space to include this information. The revised form was created on 11/22/2024. |
11/22/2024
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medication to treat the symptoms of a diagnosed psychiatric illness. Individual #1 had psychiatric medication review completed on 7/18/2024, and then again on 10/25/2024. This exceeds the at least every 3-month requirement. | 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 individual's medication review exceeded the three month period by 7 days. The medical provider will be asked to provide documentation if they are unable to accommodate an appointment within the three month review period. |
11/01/2024
| Implemented |
| 6400.166(a)(6) | Individual #1 is prescribed Sertraline HCL 100 MG Tablets with directions to Take 2 tablets (200 MG) by mouth once daily for mental health. The October 2024 Medication Administration Record states the direction are to take 200 MG by mouth once daily for mental health. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | The Program Specialist changed the MAR to reflect the correct language of the prescriber on 10/31/24. |
10/31/2024
| Implemented |
| 6400.186 | Individual #1's individual support plan last updated on 10/21/2024 states "sharp items and poisonous substances are secured." According to Program Specialist #1, Individual #1 does not require sharps to be locked. During the physical site inspection conducted on 10/30/2024, sharps were not locked in Individual #1's home. | The home shall implement the individual plan, including revisions. | The program specialist will ensure that the assessment drives the ISP. The program specialist will ensure that the assessment information is accurately captured in the individual ISP. The Program Specialist will email the Supports Coordinator to update the ISP accordingly. The program specialist was trained on 11/1/24 by the Director of Programs - to ensure the understanding that the assessment drives the ISP. The Program Specialist was re-trained on the components of the ISP and assessment. |
11/25/2024
| Implemented |
| 6400.213(1)(i) | 6400.213(1)i - Individual #1's record did not include their social security number. 6400.213(1)iii - Individual #1's record did not include the language or means of communication spoken or understood by the individual. | 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 was retrained on the individual face sheet. The Program Specialist will complete all components of the face sheet during the admissions process. The Director of Programs will complete a final review of all intake admissions forms to ensure compliance. |
11/01/2024
| Implemented |