| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | Individual #1 uses both debit and cash. The individual is not independent when managing funds. There were no up to date financial records of funds received by or deposited in the home maintained by the home for January, August, September, October, November and December for the debit transactions.
Individual #1 reported that they had no cash at the time of inspection. The last recorded remaining balance on 7/31/24 was .13. There were no up to date financial records for the cash on hand. There were no cash on hand records for the months of January, March, August, September, October, November or December. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | Individual tracking for financials was immediately implemented in the home. The individual's financials were audited and brought up to date through November 2024. Financials are currently being audited and reviewed for December 2024. |
12/30/2024
| Implemented |
| 6400.22(d)(2) | Individual #1 uses both debit and cash. The individual is not independent with financial management. There were no up to date financial records of disbursements made to or for the individual maintained in the home for January, August, September, October, November and December.
Individual #1 reported that they had no cash at the time of inspection. Last recorded remaining balance on 7/31/24 was $0.13.
There were no up to date financial records for the cash on hand. There were no cash on hand records for the months of January, March, August, September, October, November or December. | (2) Disbursements made to or for the individual.
| Individual tracking for financials was immediately implemented in the home. The individual's financials were audited and brought up to date through November 2024. Financials are currently being audited and reviewed for December 2024. |
12/30/2024
| Implemented |
| 6400.112(f) | Individual #1 moved into the home on 8/27/24. The front door was listed as the exit used for all fire drills from 8/24 to 11/24. | Alternate exit routes shall be used during fire drills. | A fire drill using an alternate exit was conducted on 12/21/2024. |
12/21/2024
| Implemented |
| 6400.113(a) | Individual #1 had annual fire safety training on 1/18/23 and again on 3/11/24. This training was not completed within the regulatory timeframe.
Individual #1 moved into the home on 8/27/24 there was no documentation of training on fire safety specific to the home upon moving into the home. | 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 was trained in in general fire safety, evacuation procedures, responsibilities during fire drills and the designated meeting place outside the building or within the fire safe area in the event of an actual fire on 12/15/2024. |
12/15/2024
| Implemented |
| 6400.141(a) | Physicals for Individual #1 were completed on 1/16/23 and 2/23/24. This exceeds the annual timeframe and additional grace period. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual annual physical exam was scheduled for 2/27/2025 to maintain compliance. |
12/30/2024
| Implemented |
| 6400.51(b)(5) | Staff #1 has a hire date 8/5/24 and first day with individuals date of 9/11/24.
Training records documented the Individual Support Plan and Behavioral Support Plan training as occurring on 11/4/24.
Both plans contain essential job-related knowledge that is required to provide proper supervision and care to the Individuals.
This training was not completed within the regulatory timeline. | The orientation must encompass the following areas: Job-related knowledge and skills. | Staff was trained on 11/4/2024 on ISP and BSP for the individual supported. |
12/15/2024
| Implemented |