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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | The hot water in the home measured at 123.8 degrees. This was over the regulatory 120 degrees. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Program Director called to Spring Ridge apartment office and spoke with Chantelle. Notified her of the water temperature. Requested her permission for agency's maintenance to put a mixed Value or if they can put it. she stated she will check and get back to Director. A week later she stated they can not do it and agency is not allowed to do that. |
01/02/2025
| Implemented |
| 6400.77(b) | The first aid kit in the home did not contain tape and gauze. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | The First Aid Kit now has a tape and gauze. |
12/16/2024
| Implemented |
| 6400.181(e)(9) | The agency did not assess Individual #1 appropriately in their area of functional limitations.
Individual #1's assessment dated 10/3/24 stated under the function limitation section "no functional limitations". Individual #1's Individual Support Plan (ISP) last updated 12/9/24, states under the know and do section that Individual #1 can complete easier tasks, more in-depth tasks require repeating as well as asking prompting questions, at times Individual #1's behavior can impede progress. Under functional information in the physical development section, Individual #1's ISP states "Individual #1 struggles with fine motor skills". The social/emotional section, Individual #1's ISP states "Individual #1 has a strong desire to be liked by peers. At times, Individual #1 will also antagonize peers, at times Individual #1 can be impulsive which impedes Individual #1's abilities. At times, Individual #1 will also engage in emotional manipulation with new clinical provides/school personnel/staff, which results in patterns of inpatient hospitalization." Individual #1's ISP states in the psychosocial section "Individual #1 has a history of self-harm and suicidal ideation. Individual #1 has had numerous mental health hospitalizations over the past several years, Individual #1 has been aggressive with staff and peers in the past and if escalated, may engage in aggressive behaviors again. Individual #1 benefits from having 1:1 staffing in the home and at day program to assess individual needs and ensure safety. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | The PS and site Supervisors Retrained. The individual's Functional assessment is corrected. A copy of the Individual's correct Functional assessment and staff training sign in sheet email to Kristen. |
12/17/2024
| Implemented |
| 6400.169(a) | A staff person who has successfully completed a department-approved medication administration course, including the course renewal requirements, may administer medications, injections, procedures, and treatments. Office of Developmental Programs (ODP) Announcement 23-075, Publication dated 9/13/2023, Medication Administration paper course Discontinuation Reminder and train-the trainer fall schedule stated that In November 2022, it was announced that the use of older versions of the training course would no longer be permitted after December 31, 2023. The use of the 2004 paper course, and the 2004 and 2013 manuals will not be permitted for new student candidates after December 31, 2023. After December 31, 2023, unlicensed staff can only become qualified to administer medications by using the online Medication Administration Training Course. Staff #1 medication administration course was completed on 7/16/24 using the paper course not the required online Medication Administration Training Course. The agency is not conducting Staff medication administration training as prescribed by the medication administration training course, and therefore staff #1 is not qualified to administer medication as they did not become qualified by using and completing the online Medication Administration Training Course. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | The staff has been Retrained using the online medication training. A copy of their certificate email to Kristen. |
12/25/2024
| Implemented |
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