| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(a) | The window on the right in Individual #1's bedroom did not have screen. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Lifesteps Buildings and Grounds staff installed the window screen on March 11, 2022. |
03/31/2022
| Implemented |
| 6400.141(a) | Individual #1's most recent physical examination was completed on 2-15-21. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Guardian scheduled individual #1 for physical on March 28, 2022. [As per Chief program officer on 4/6/2022, Individual #1's guardian confirmed Individual completed the scheduled physical examination on 3/28/22. Individual #1 is not currently living in the home and will not return according to Individual #1's guardian. ((AES,HSLS(4/6/2022)] |
03/31/2022
| Implemented |
| 6400.141(c)(9) | Individual #1's most recent prostate test (PSA) was completed on 1-4-21. | The physical examination shall include: A prostate examination for men 40 years of age or older. | Guardian scheduled individual #1 for prostrate examination (PSA) on March 28, 2022. [As per Chief program officer on 4/6/2022, Individual #1's guardian confirmed Individual completed the scheduled physical examination on 3/28/22 but did not have the prostate examination, this testing is to be rescheduled by Individual #1's guardian. Individual #1 is not currently living in the home and will not return according to Individual #1's guardian. (AES,HSLS(4/6/2022)] |
03/31/2022
| Implemented |
| 6400.181(a) | Individual #1, date of admission 5-10-21, had an initial assessment completed on 7-27-21. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Lifesteps Program Specialists will be retrained on Regulations 6400.181-190, including information in the Regulatory Compliance Guide by April 1, 2022. |
04/01/2022
| Implemented |
| 6400.165(g) | Individual #1's psychiatric medication reviews, completed 10-27-21 and 8-4-21, did not include the necessary dosage. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Documentation for Individual #1's psychiatric medication reviews, including necessary dosage was received from doctor's office on March 4, 2022. |
03/31/2022
| Implemented |
| 6400.166(a)(8) | Individual #1 was prescribed Triple Paste Ointment on 5/20/21. The February 2022 and March 2022 Medication Administration Records states, "Apply topically as directed every morning for prevention of infection." The medication label states, "Apply topically to the rectum once daily (prevention of infection)." | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | New labels were received from the pharmacy for the medication to replace incorrect label on March 4, 2022. |
03/31/2022
| Implemented |
| 6400.166(a)(11) | Individual #1's March 2022 Medication Administration Record does not include the diagnosis or purpose for Clobetasol cream. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Updated Medication Administration Record was received by Community Home Supervisor from the pharmacy on March 4, 2022. |
03/31/2022
| Implemented |
| 6400.181(f) | The program specialist provided Individual #1's assessment, completed 7-27-21 to the plan team members on 7-27-21 for the annual ISP meeting on 7-30-21 | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Lifesteps Program Specialists will be retrained on Regulations 6400.181-190, including information in the Regulatory Compliance Guide by April 1, 2022. |
04/01/2022
| Implemented |