| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.106 | The furnace was inspected 2/03/2021, 7/20/2021, 1/13/2022, and 6/29/2022 but there is no documentation it was cleaned by a professional cleaning company | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| Maintenance staff will be re-certified to inspect and clean the furnace. The Certification will be kept on file. A form will be developed to document the date the Maintenance staff will clean furnaces and inspect the furnace. The furnace will be re-inspected and re-cleaned by October 1, 2022. |
10/01/2022
| Implemented |
| 6400.113(c) | Individual #1's fire safety training did not include the content of the training. | A written record of fire safety training, including the content of the training and a list of the individuals attending, shall be kept. | Descriptive content detailing what individuals are instructed on during monthly fire drills was developed and will be distributed to all homes as a resource for staff completing the drill and instructing consumers |
09/05/2022
| Implemented |
| 6400.165(g) | Individual #1 had a psychiatric medication review 12/15/2021 and then again 3/24/2022. Individual #1's most recent psychiatric medication review occurred 4/19/2022 and not again since. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Consumer had psychiatric medication review completed on 6/9/22 and scheduled for 9/8/22 |
09/01/2022
| Implemented |
| 6400.181(f) | Individual #1's assessment completed 1/24/2022, was provided to the individual plan team members 7/13/2022, for the individual service pan meeting that occurred 2/17/2022. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Program specialist will ensure that assessment is completed bi-annually and sent 30 days prior to the ISP to the treatment team |
09/08/2022
| Implemented |
| 6400.183(c) | Individual #1's annual individual service plan meeting occurred 2/17/2022, and did not include documentation with a list of persons who participated in the meeting. | The list of persons who participated in the individual plan meeting shall be kept. | ISP signature page listing persons in attendance has been requested. |
09/08/2022
| Implemented |