| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(b) | One of the home's basement windows had a hairline crack in its windowpane. | Screens, windows and doors shall be in good repair. | The window is scheduled to be preplaced on 08/12/2024. |
08/12/2024
| Implemented |
| 6400.106 | The latest furnace inspection on record for this location was conducted on 10/25/2022. There was no evidence of a more recent furnace inspection occurring. The furnace at this location was not inspected annually as required. | 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.
| Furnace was inspected on 7/17/24. |
07/17/2024
| Implemented |
| 6400.142(f) | The provider reported that Individual #1 completes dental hygiene independently; however, this information was not found within the individual's Individual Record. There was no dental hygiene plan found for Individual #1 within the individual record. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | The consumers Dental Plan was written but did not include the level of independence necessary to complete his hygiene routine. The plan was updated to include the Individuals level of independence. |
07/17/2024
| Implemented |
| 6400.151(c)(3) | Staff #1's Physical Examination, dated 07/08/2024, does not note whether this staff was free from communicable disease. There was a line item on the form asking, "IS THE INDIVIDUAL FREE FROM COMMUNICABLE DISEASES?"; however, the medical professional completing the form did not respond to this question. This information was not found elsewhere in the physical. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | On 07/10/2024 we received an updated "free from communicable disease" report from the panel provider the staff received their PPD test from. |
08/12/2024
| Implemented |
| 6400.15(b) | The self-assessment of this location, conducted 06/01/2024, was completed on the Department's "Self-Inspection and Declaration Tool," which is intended to be used for opening a new location, rather than the Department's "Self-Assessment Licensing Inspection Instrument," which is intended to be used for the annual self-assessment of a location. In addition, the self-assessment was not completed at least 3-6 months prior to the provider's 07/12/2024 license expiration date. As such, there was no valid self-assessment conducted for this location as is required within the specified time frame. | (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. | Standard Operating Procedure was created for the Residential Licensing process. |
08/31/2024
| Implemented |
| 6400.181(f) | An email in the Individual Record notes that the Program Specialist sent the Individual Assessment to the members of Individual #1's Individual Plan Team on 11/09/2023. This was less than 30 calendar days prior to Individual #1's Individual Plan Meeting on 11/21/2023. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | We completed a training with our Client Services Department about the importance of timeframes. |
07/17/2024
| Implemented |