| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | At 10:03 AM on 1/30/25, the ceiling on the inside of the microwave was stained with food remnants and its interior surface finish was delaminating. | Clean and sanitary conditions shall be maintained in the home. | As of 1/30/2025:
The old microwave, with stained ceilings and delaminating interior surfaces, was removed from the home and properly disposed.
A brand new microwave has been purchased and placed into the home.
(see attached receipt of purchase) |
01/30/2025
| Implemented |
| 6400.80(b) | At 9:56 AM on 1/30/25, the sidewalk leading to the front door of the home had a crack that measured approximately one-half inches wide and two feet, six inches in length, causing a potential tripping hazard. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The sidewalk leading to the front door of the home with a crack approximately one-half inch wide and two feet, six inches in length, causing a potential tripping hazard, has been repaired as of 2-3-2025.
(see picture attached) |
02/03/2025
| Implemented |
| 6400.141(c)(4) | Individual #2's date-of-admission is 12/19/24. Their pre-admission physical examination, completed on 12/16/24, did not include vision or hearing screenings. Individual #2 had a vision examination completed on 1/17/25 and a hearing examination completed on1/28/25. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Effective 2-18-2025
ALC has implemented our electronic health record system called Assisted Living Intelligent Solutions also known as ALIS.
Going forward the medical records coordinator will use ALIS to ensure that individual's physicals are completed fully prior to admission. |
02/18/2025
| Implemented |
| 6400.141(c)(11) | Individual #1 had a physical examination completed on 2/6/24. Individual #1 was indicated to have an iron deficiency on this physical examination. However, their physical examination, completed on 2/6/24, did not include an assessment of the individual's need for blood work at recommended intervals. | 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. | ALC used Individual #1's physical form from the individual's doctor's office prior to admission. This physical form did not indicate if blood work was required.
Going forward, Individual #1will use ALC's physical form for all physical examinations in the future. |
02/18/2025
| Implemented |
| 6400.141(c)(14) | Individual #2's most recent physical examination was completed on 12/16/24. However, this physical examination did not include medication information pertinent to diagnosis and treatment in case of an emergency. The field was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | ALC has implemented our electronic health record system called Assisted Living Intelligent Solutions also known as ALIS.
Medical Records coordinator and Administrative coordinator will preform the 2-step review process. This will ensure that all medical information pertinent to diagnosis and treatment in case of an emergency is documented. |
02/18/2025
| Implemented |
| 6400.15(b) | The agency used the Self-Inspection and Declaration Tool, modified June 2018 to measure and record compliance at the home on December 28, 2024, which does not contain all the elements in the current Department's licensing inspection instrument released on February 20, 2020. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | ALC has disposed of all copies of the self-inspection and declaration tool modified june-2018 and replaced them with the correct version modified Feb-2020 as located in the regulatory compliance guide printed March 15,2023.
Compliance managers , who are responsible for completing the self-inspection and declaration tool, were trained 2-10-2025 that going forward, the self inspection and declaration tool modified Feb-2020 is the correct form to be used when conducting home inspections. |
02/10/2025
| Implemented |
| 6400.182(b) | Individual #1's date-of-admission is 7/13/24. Their initial assessment was completed on 8/31/24. This assessment was sent to individual plan team members on 1/18/25, for development of an initial Individual Support Plan, which is beyond 90 days of Individual #1's date-of-admission. | The initial individual plan shall be developed based on the individual assessment within 90 days of the individual's date of admission to the home. | The CEO gave the Program specialist an assessment tracking spreadsheet. The spreadsheet provides the dates the assessments are to be completed, and when to be sent to team members. This will ensure the assessment will be sent to the support coordinator within 90 days of the individual's admission date going forward.
Additionally, ALC has implemented our electronic health record system called Assisted Living Intelligent Solutions also known as ALIS. Individual assessments dates will be uploaded and tracked in the ALIS System. |
02/14/2025
| Implemented |