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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.182(c) | Individual #1's current assessment, completed on 4/1/24, and their Individual Support Plan, last updated on 12/20/24, differed in several safety skill domains in the following manner: Individual #1's assessment explained that they understand warning labels, but may have difficulty reading certain labels and following directions while their Individual Support Plan indicated they can identify most poison labels but not all due to poor reading skills. However, they require verbal prompting when around or using such substances; Individual #1's assessment indicated that they can respond to fire drills and meet at the designated area with verbal prompting. However, their Individual Support Plan stated they can independently evacuate the building in the event of a fire; Individual #1's assessment informed that they require a 1:1 staff-to-individual ratio at home and in the community with line-of-sight supervision. However, their Individual Support Plan explained that they a require 2:1 staff-to-individual ratio in the home due to physical aggression towards staff and that they can have private time in the bathroom and bedroom. Individual #1 is required to be within auditory range during all other times for verbal redirection. In the community, Individual #1 needs total visual supervision, cannot be left unattended around female children, but can use public restrooms alone. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | individual # 1 current assessment was updated on 12/27/2024 , it now includes safety skills, fire evacuation, staff ratio and community supervision. On 1/6/2025 a meeting was held with individual # 1 support team to review the updates. |
01/03/2025
| Implemented |
| 6400.195(a) | Individual #1's current assessment, completed on 4/1/24, indicated that sharp objects should be securely stored. Their Individual Support Plan, last updated on 12/20/24, explained that sharps are kept locked in Individual #1's home due to a "history of aggression." However, the component of Individual #1's Individual Support Plan addressing behavior support that is reviewed and approved by the human rights team and that had last been updated on 5/22/24, did not include this restriction of having all sharp objects in the home locked. On 12/27/24, sharp objects were found locked underneath the kitchen sink. | For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures. | The positive behavior support plan with restrictive procedure plan was revised on December and approved by human right team on dec 31st 2024. The plan now reflects locking of sharps objects. |
01/03/2025
| Implemented |
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