| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(e)(1) | Individual #1's Individual Support Plan lasted updated 12/27/2024 as well as their assessment completed on 12/03/2024 state the individual is unable to manage spending money independently and requires total staff assistance. A separate record of financial resources, including the dates and amounts of deposits and withdrawals was not provided during the documentation review. [Repeated violation: 4/30/2024 et al] | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. | Program specialist made the correction in the assessment and review section. the correction was the fiscal department will have staff bring the cash on ledger up every Tuesday to ensure compliance and she will red line and date for accuracy. |
01/09/2025
| Implemented |
| 6400.143(a) | Individual #1 refused a pap test on 12/21/2023. The refusal and continued attempts to train the individual about the need for health care was not documented in the record. | 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. | The nurse will train and educated the individual on 1/21/2025 on the importance of the recommended care. |
01/21/2025
| Implemented |
| 6400.181(e)(12) | Individual #1's assessment completed 12/03/2024 did not include any recommendations for specific areas of training, programming and services. [Repeated violation: 8/6/2024 et al] | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The program specialist updated the assessment on 1/13/2025 and was added to her assessment for 12/4/2024 |
01/13/2025
| Implemented |
| 6400.15(b) | The self-assessments completed on 5/23/2024, 11/23/2024, and 12/28/2024 were completed on the 6400 Scoresheet that was last updated in June 2018. This scoresheet does not measure compliance with all the current 6400 regulations. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | The agency will immediately (1/8/2025) transition to using the Department's licensing inspection instrument for community homes to measure and record compliance, The outdated scoresheet used on 5/23/2024, 11/23/2024, and 12/28/2024 will no longer be utilized. |
01/08/2025
| Implemented |
| 6400.182(c) | Individual #1's individual support plan last updated 12/27/2024 states the individual requires assistance from caregivers to temper water. Individual #1's assessment completed on 12/03/2024 states the individual tempers water independently. Interviews with agency staff revealed that the individual can independently temper water; however, the individual's ISP has not been updated to accurately reflect this ability. [Repeated violation: 8/6/2024 et al] | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The program specialist on 1/9/2025 contacted the supports coordinator and requested that a change be made in the ISP to state the individual can temp their own water. This change was made on 1/9/2025. Program specialist compared updated ISP to assessment and noted the discrepancy has been corrected. |
01/09/2025
| Implemented |