| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(a) | Individual #1 was an emergency placement and moved into the home on 6/26/2023. Individual #1's initial physical examination was completed on 8/17/2023. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | 02/16/2024 Chief Program Officer created New Residential Placement Checklist to include physical examination, vision, hearing, dates completed, etc. |
02/16/2024
| Implemented |
| 6400.181(a) | The initial assessment for individual #1, whose date of admission is 6/26/2023, was completed on 9/1/2023. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | 09/01/2023 Individual #1's initial assessment was completed.
02/16/2024 Chief Program Officer created New Residential Placement Checklist which includes initial assessment to ensure completion of required documentation of initial assessment. |
02/16/2024
| Implemented |
| 6400.181(d) | Individual #1's initial assessment, completed on 9/1/2023, was not signed by the program specialist. | The program specialist shall sign and date the assessment. | 02/15/2024 Program Specialist signed and dated Individual #1's initial assessment. |
02/15/2024
| Implemented |
| 6400.181(e)(2) | Individuals #1's initial assessment, completed on 9/1/2023, did not contain the individual likes, dislikes, and interests. This section of the assessment was left blank. [Repeat violation: 2/22/2023, et al.] | The assessment must include the following information: The likes, dislikes and interest of the individual. | 02/20/2024 Program Specialist updated the assessment to include individual likes, dislikes, and interests. |
02/20/2024
| Implemented |
| 6400.34(a) | Individual #1 was an emergency placement and moved into the home on 6/26/2023. Individual #1 was initially informed of their rights on 10/13/2023. [Repeat violation: 2/22/2023, et al.] | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | 10/13/2023 Individual #1 signed Individual Rights policy.
02/16/2024 Chief Program Officer created New Residential Placement Checklist which included Individual Rights to ensure completion of required documentation of Individual Rights Training. |
10/13/2023
| Implemented |
| 6400.166(a)(11) | On 1/31/2024 at 11:45am, the following medication prescribed to individual #1 did not include a diagnosis or purpose for the medication on the January 2024 medication administration record: Fluticasone 50mcg nasal spray, Lorazepam 1mg tab, Pantoprazole sod 40mg tab. [Repeat violation: 2/22/2023, et al.] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | 01/31/2024 Nurse Supervisor Community Homes Nurses corrected the MAR by adding the 3 missing diagnosis.
02/07/2024 Nurse Supervisor Community Homes ran an ALL Medications with Blank Diagnosis report on eMAR; missing diagnosis were added. |
01/31/2024
| Implemented |