| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency did not complete a self-assessment of the home within 3 to 6 months prior to the expiration date of the agency's certificate of compliance. On the self-assessment provided, with a completion date of "August 2024," the following regulations were left blank: 6400.165(f) and 6400.213(8). | 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.
| To correct the violation, LRS will implement a physical site inspection checklist that the team leads for each location will complete monthly to maintain all sites in compliance. LRS will also begin the self-assessment on March 1st, six months before the certification of the compliance expiration date. The self-assessment must be completed in its entirety and forwarded to Mr. Andrew Wimbish, President, by May 31, 4 months before the certification of the compliance expiration date. The self-assessment will include the beginning and end dates on which the assessment was conducted. The completed self-assessments with supporting documentation will be maintained in the LRS shared drive. |
09/13/2024
| Implemented |
| 6400.113(a) | Individual #1 had fire safety training on 1/10/2023 and then again on 7/26/2024. This exceeds the annual requirement. | 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 Compliance Director, Program Specialist, and COO were trained on 6400.113a regulation of providing individuals with Fire Safety training upon admission and annually thereafter. All individuals will be trained on Fire Safety on 1/5/2025 and annually thereafter. |
09/25/2025
| Implemented |
| 6400.34(a) | Individual #1 was informed of their individual rights and the process to report a rights violation on 1/1/2023, and then again on 5/10/2024. This exceeds the annual requirement. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | The Compliance Director, Program Specialist, and COO were trained on 6400.34 regulations regarding informing and explaining individual rights and the process to report a rights violation upon admission to the home and annually thereafter. All individuals will be trained on Individual Rights on 1/5/2025 and annually thereafter. |
09/02/2024
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medication to treat the symptoms of a diagnosed psychiatric illness. Individual #1 had a psychiatric medication review on 7/1/2024; however, the form did not include the purpose or reason for prescribing the medications. Individual #1 had a psychiatric medication review on 8/21/2023, and then again on 12/6/2023. This exceeds the at least every 3-month requirement. [Repeat violation 8/15/23, et. al.] | 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. | An updated 90-day medication review form has been developed to include the NEXT APPOINTMENT DATE to be completed before leaving the doctor¿s office.
The updated Psych Review Form has been uploaded to the Department¿s shared drive. |
09/04/2024
| Implemented |
| 6400.213(7) | There was no record of the Individual #1's annual plan meeting held on 6/11/2024. The agency did not provide a sign in sheet or recorded list of attendees. | Each individual's record must include the following information: Individual plan documents as required by this chapter. | All team leads, who attend ISP meetings, the Program Specialist, and the Compliance Director were trained on the process of collecting ISP sign-in sheets and ISP invitational letters when attending the meeting with the individual and treatment team. Missing ISP sign in sheet was obtained and filed in the Individual's Program Binder. |
09/04/2024
| Implemented |