| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(e)(3) | Receipts for purchases over the amount of $15 were not maintained in Individual #1's record. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | Individual 1 has legal guardians who give staff money for Individual 1 to spend. Staff maintain a ledger at the home so that the guardians have accurate information on how the money was spent.
SHS did not realize that since we were not representative payee that we had to keep a copy of these receipts. Upon realizing this, we have implemented that a copy of all receipts be made as soon as a purchase has been made and this copy will be retained for SHSs records. Staff have been trained on this new protocol and a verification form is attached. (Attachment # 5) |
08/11/2020
| Implemented |
| 6400.110(f) | Individual # 1 is hearing impaired and is prescribed hearing aids, as evidenced by her medical records. Per Individual #1's ISP dated 7/6/20, at times she refuses to wear her hearing aids. The fire system in Individual #1's home isn't equipped to alert her of a fire when she isn't wearing her hearing aids. | If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. | All ISPs have been reviewed as well as physicals to ensure that no other individuals residing with SHS has any type of hearing impairment. SHS has purchased a Bellman Visits, Smoke alarm Transmitter, Pager, Charger, and Bed Shaker for this individual. (Attachment #6)
The pager will be cared on individuals person when in the home and awake. The pager will be placed in the charger nightly to ensure full charge for the day. The bed shaker will also be placed on the bed of the individual so that she may be alerted during sleeping hours.
Supports Coordinator has been notified to ensure proper documentation in the ISP as well as her assessment has been updated and distributed. (Attachment #7) |
08/11/2020
| Implemented |
| 6400.113(a) | Individual #1's date of admission was 10/3/19. Individual #1 did not receive fire safety training until 10/4/19; outside of the regulatory time frame. | 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 moved in on 10/03/2019 in the late evening. Upon arriving at the home she did participate in a fire drill. Individual 1 and her guardians then helped set up her room and socialized with her housemate and staff. Upon leaving the home staff went over the fire safety form but it was after midnight which technically made it the next day.
SHS has implemented that the fire safety outline will be competed immediately when the individual arrives at the home. The Assistant Program Specialist will be responsible for ensuring that this happens and has been trained by the CEO on this procedure. (Attachment # 8) |
08/11/2020
| Implemented |
| 6400.181(e)(13)(iii) | Individual #1's initial assessment completed on 11/27/19 did not assess her daily living skills. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | Individual 1 assessment has been updated (Attachment #2) and all information in regards to activities of daily living has been incorporated into an addendum and reviewed with individual 1 and sent to her team. This assessment was the initial assessment and not areas was reported on.
The Program Specialist as well as the Assistant Program Specialist will both review all assessments prior to disbursement to the team for accurate information and that all areas have been addressed. All assessments completed by SHS will comply with the 6400 regulations and an assessment outline will be followed (Attachement#3). At any time if information has changed for the individual an addendum will be completed, reviewed, and sent to the team and documentation will be kept. |
08/11/2020
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's initial assessment completed on 11/27/19 did not assess how she manages financial independence. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| Individual 1 assessment has been updated (Attachment #2) and all information in regards to financial independence has been incorporated into an addendum and reviewed with individual 1 and sent to her team. This assessment was the initial assessment and not areas was reported on.
The Program Specialist as well as the Assistant Program Specialist will both review all assessments prior to disbursement to the team for accurate information and that all areas have been addressed. All assessments completed by SHS will comply with the 6400 regulations and an assessment outline will be followed (Attachement#3). At any time if information has changed for the individual an addendum will be completed, reviewed, and sent to the team and documentation will be kept. |
08/11/2020
| Implemented |
| 6400.181(e)(13)(viii) | Individual #1's initial assessment completed on 11/27/19 did not assess how she manages her personal property. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | Individual 1 assessment has been updated (Attachment #2) and all information in regards to managing personal property has been incorporated into an addendum and reviewed with individual 1 and sent to her team. This assessment was the initial assessment and not areas was reported on.
The Program Specialist as well as the Assistant Program Specialist will both review all assessments prior to disbursement to the team for accurate information and that all areas have been addressed. All assessments completed by SHS will comply with the 6400 regulations and an assessment outline will be followed (Attachement#3). At any time if information has changed for the individual an addendum will be completed, reviewed, and sent to the team and documentation will be kept. |
08/11/2020
| Implemented |