| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.73(a) | On 12/4/24, at 10:10 AM, there was no well-secured handrail on the ten exterior concrete stairs leading from the basement exit to the back exterior of the home. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | On 12/4/24, a secured handrail was installed on the exterior steps at the service location. A picture of the completed task was taken and submitted to the licensing agent. |
12/04/2024
| Implemented |
| 6400.107 | On 12/4/24, at 10:43 AM, a portable space heater was hanging on a hook in the detached garage of the home. | Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including staff rooms.
| The portable Heater was removed during the inspection of the service location. |
12/04/2024
| Implemented |
| 6400.143(a) | Individual #1 refused a diabetic eye examination on 11/19/2024. There was no documentation of continued attempts to train the individual about the need for health care. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | Individual # met with the Residential Coordinator on 12/4/2024, at which time they discussed their reasoning for canceling an appointment (s/he wanted to attend a social event) and signed a refusal form |
12/04/2024
| Implemented |
| 6400.181(e)(10) | Individual #1's assessment completed on 9/20/2024 did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | Individual records(Assessments) were updated with lifetime medical history(limited to what Valley Advantages could validate from appointment records on site). Medical History updates were sent to SC |
12/05/2024
| Implemented |
| 6400.161(e)(1) | Individual #1 is self-administering medications with no Medication Administration Record being kept. Individual #1's assessment completed 9/20/2024 states that verbal and physical prompts are needed to complete the steps of medication administration. Individual #1's Individual Service Plan last updated 11/13/2024 states that Individual #1 does not self-administer medications. | To be considered able to self-administer medications, an individual shall do all of the following: Recognize and distinguish the individual's medication. | Individual #1 no longer self-administers medications; s/he receives them from a DSP who has successfully passed ODP medication administration training. S/He will have an assessment to determine the knowledge needed for Self-Administration (161(e) (1). |
12/04/2024
| Implemented |
| 6400.163(b) | On 12/4/24, at 10:27 AM, Individual #1's prescribed 12:00 PM and "Bedtime" medications were removed from their originally labeled blister packets and pre-dispensed into a timed pill dispenser with an alarm by staff to assist Individual #1 to self-administer the medications. | A prescription medication may not be removed from its original labeled container in advance of the scheduled administration, except for the purpose of packaging the medication for the individual to take with the individual to a community activity for administration the same day the medication is removed from its original container. | The Safe at Home pill dispenser was removed from the service location. Pills were repacked from the pharmacy, and Individual #1 received his/her medication from a Medication Administration. |
12/04/2024
| Implemented |