| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 20.71(a)(7) | Upon realizing that two months' worth of financial records were missing for Individual 1, the Licensing Representative requested those records be sent through email. The agency submitted financial records that were all in the same handwriting with all different dates and staff initials. Almost every amount was at or under $15, which means no receipts were required to be submitted. When questioned about these documents, the agency stated that the original records were "messy and hard to read" but the original records were never submitted, and it is unknown if they ever existed. | The Department may deny, refuse to renew or revoke a certificate of compliance for fraud or deceit in obtaining or attempting to obtain a certificate of compliance. | The agency has addressed this issue by standardizing all Financial Records across the agency for every individual residing in our homes. The agency requires every Financial Record to record the full Dollar and Cent amount for every transaction. The agency has Trained all staff on the Policy and Protocols to address proper and full documentation, accurate count balances, audits on- going, proper use of individual's monies, provide assistance to individuals in need and document that need through the use of the Financial Record. Please see the Training sheets with On site trainings and the use of e-Training platform Relias transcripts. |
06/11/2024
| Implemented |
| 6400.22(e)(1) | Upon a review of Individual #1's financial records, documentation of financial resources, including deposits and withdrawals, could not be located for the following months of the review period: April 2023 and May 2023. There was no documentary evidence that the provider maintained such a record for Individual #1 during those months. | 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. | The agency has addressed this issue by standardizing all Financial Records across the agency for every individual residing in our homes. The agency requires every Financial Record to record the full Dollar and Cent amount for every transaction. The agency has Trained all staff on the Policy and Protocols to address proper and full documentation, accurate count balances, audits on- going, proper use of individual's monies, provide assistance to individuals in need and document that need through the use of the Financial Record. Please see the Training sheets with On site trainings and the use of e-Training platform Relias transcripts. |
06/11/2024
| Implemented |
| 6400.141(c)(11) | Individual #1's physical examination, dated 11/14/2023, did not contain an assessment of the individual's health maintenance needs, medication regimen, or the need for blood work at recommended intervals. The corresponding item on the physical form was left blank by the medical professional completing the form. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | Agency has developed a Tracker Sheet for Residential Directors use for each home that will serve as tracking for full and timely documentation such as Medical Appointments and completion of vital information specific to required Immunizations such as Individual's health maintenance, medications or need for bloodwork. |
04/19/2024
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination, dated 11/14/2023, did not note medical information pertinent to diagnosis and treatment in case of an emergency. The corresponding item on the physical form was left blank by the medical professional completing the form. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Agency has developed a Tracker Sheet for Residential Directors use for each home that will serve as tracking for full and timely documentation such as Medical Appointments and completion of vital information specific to diagnosis and treatment in case of emergency. |
04/19/2024
| Implemented |
| 6400.151(c)(3) | Staff #1's physical examination, dated 01/31/2024, did not contain a signed statement that the staff was free from communicable diseases. | 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. | The agency HR Representative has directed the Staff person to return to the medical provider with another agency form for completion in it's entirety. |
04/19/2024
| Implemented |
| 6400.151(c)(4) | Staff #1's physical examination, dated 01/31/2024, did not note whether or not the staff had medical problems that might interfere with the health of the individuals. | The physical examination shall include: Information of medical problems which might interfere with the health of the individuals. | The agency HR Representative has directed the Staff person to return to the medical provider with another agency form for completion in it's entirety. |
04/19/2024
| Implemented |
| 6400.181(f) | There was no documentary evidence to show that the Program Specialist provided Individual #1's Individual Assessment to the members of the Individual Plan Team at least 30 calendar days prior to the Individual Plan Meeting on 04/20/2023. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The agency has placed a checklist on the last page of the Assessment along with the formal Transmittal Letter previously used for proof of Assessment copies made available to designated persons per the regulatory requirements. |
04/19/2024
| Implemented |
| 6400.183(c) | Individual #1's Individual Record did not contain a record of the persons who participated in the Individual Plan meeting on 04/20/2023. | The list of persons who participated in the individual plan meeting shall be kept. | The agency Representative has requested the ISP Signature Sheet from the Supports Coordinator in this specific case and is awaiting a copy from the same. The agency will keep a copy of the signature sheet for every ISP moving forward. |
04/19/2024
| Implemented |