| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(e)(2) | Jami is representative payee for Individual 1 -- agency sends their personal spending money to Individual 1's significant other via CashApp but no written record is on file to show the arrangement is Individual 1's individual choice. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: For a withdrawal when the individual is given the money directly, the record shall indicate that funds were given directly to the individual. | DPOC: The agency will conduct staff trainings on management of an individual's finances for all DSPs and administrative staff. The agency will develop new procedures and policies to ensure all requirements for the management of an individual's finances are met. Documentation will be developed to ensure this, including consent forms that must be reviewed and signed annually, and the agency will meet with individuals for whom they are rep-payees to explain their rights and updates on how their finances will be managed. This must include information on how the individual can participate in this process and guide it. |
03/13/2025
| Not Implemented |
| 6400.113(a) | Individual 1's 2023 fire safety training is not in the individual's record; annual compliance could not be determined. [REPEAT VIOLATION] | 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. | Individual 1's Fire safety training was completed on September 5, 2023. |
10/25/2024
| Not Implemented |
| 6400.141(a) | Individual 1's physical exams do not meet the criteria for annual completion. Last two physical exams were completed 08/05/2024 and 06/29/2023. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual 1 refused to attend the scheduled appointment in June of this year. Appointment was rescheduled by the agency nurse for August 5, 2024. |
10/25/2024
| Not Implemented |
| 6400.141(c)(13) | For individual 1, the sections for allergies and contraindicated medications were left blank on the most recent physical. | The physical examination shall include: Allergies or contraindicated medications. | Individual 1's physical form was returned to his primary care physician to have the allergies and contraindicated medication completed. Both sections were updated and returned to provider nursing agency. |
10/25/2024
| Not Implemented |
| 6400.141(c)(14) | For Individual 1, the section "information pertinent to diagnosis and treatment in case of emergency" was left blank on the most recent physical. [REPEAT VIOLATION] | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Individual's 1 physical form was returned to the Doctor to have the diet question answer. The physical form was updated and returned to the provider. Provider will file document in individual's medical binder. |
10/25/2024
| Not Implemented |
| 6400.141(c)(15) | For Individual 1, the section for special instructions for individual's diet was left blank on the most recent physical. [REPEAT VIOLATION] | The physical examination shall include:Special instructions for the individual's diet. | Individual's 1 physical form was returned to the Doctor to have the diet question answer. The physical form was updated and returned to the provider. Provider will file document in individual's medical binder. |
10/25/2024
| Not Implemented |
| 6400.142(a) | Individual 1 had no records of dental examinations on file. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Individual 1 attended his scheduled dental appointment on October 1, 2024. Dental visit form will be filed in his medical binder. |
10/25/2024
| Not Implemented |
| 6400.144 | For individual 1, the optometrist indicated an appointment should be scheduled in July 2024 for follow-up but was not completed. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Individual attended the follow up vision appointment on July 24, 2024. Medical visit form will be filed in the individual's medical binder at the service location and at the main office. |
10/25/2024
| Not Implemented |
| 6400.51(b)(5) | Staff Member 1 did not receive orientation training in job knowledge and skills within a month of their hire date of 05/27/2024. | The orientation must encompass the following areas: Job-related knowledge and skills. | The provider implemented an annual training plan for each staff member which covers all required training. The annual training planned will have a list of the required training, the date training was completed, and next due date of training for each staff member. All training records will be filed in each employee¿s file for record keeping purposes. |
10/25/2024
| Not Implemented |