| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.113(a) | Individual #3 moved into his current apartment on 10/6/24 from another agency apartment. Fire safety training for the individual did not occur until 12/20/24. Fire safety training the previous year was 12/20/23. However, the individual should have had fire safety training upon admission to the new home. The fire drill form provided during inspection was dated when the individual was admitted to a rehabilitation facility in October and physically out of program. Agency staff stated this was an error in dating the form. However, there was no backup documentation available to prove that a fire drill had actually occurred between the move-in date and the date that the individual was admitted to the hospital during the month of October. | 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. | Violation 113 (a) has been corrected. See POC attachment # 5. Moving forward, Provider will ensure compliance with making individual annual fire safety is modified during in-house admission even though one was completed on 12/20/2024 reflecting new address. |
04/25/2025
| Implemented |
| 6400.18(i) | Incident #9503596 for Individual #3 (discovery date 10/23/24) was originally due on 1/10/25. An extension was entered on 1/17/25 with anticipated completion date of 2/9/25. The incident is still open at the time of inspection. | The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension. | Violation has been corrected. See POC attachment # 6. Moving forward, agency will reinforce dashboard monitoring and ensure all incidents are entered timely into EIM. Additionally, to address late reporting, agency has recruited new IM staff to maintain compliance. |
05/20/2025
| Implemented |
| 6400.18(j)(4) | Incident #9560262 for Individual #3 (discovery date 8/26/24) was documented as entered late with reason provided. Initial regional management review on 1/30/25 then requested that corrective action be added in the final section, but corrective action was not entered as requested. Incident is still open at time of inspection.
A second report, Incident #9560249 for Individual #3 (discovery date 7/24/24) was documented as entered late with reason was provided. Initial regional management review on 1/30/25 then requested that corrective action be added in the final section, but corrective action was not entered as requested. Incident is still open at time of inspection. | The home shall provide the following information to the Department as part of the final incident report: A description of the corrective action taken in response to an incident and to prevent recurrence of the incident. | Violation has been corrected. See POC attachment # 7. Moving forward, agency will reinforce dashboard monitoring and ensure all incidents are entered timely into EIM. Additionally, to address late reporting, agency has recruited new IM staff to maintain compliance. |
05/20/2025
| Implemented |
| 6400.183(a)(1) | The ISP signature form for Individual #3's 12/3/24 ISP meeting does not indicate whether the individual was present at the ISP meeting or if the results were reviewed with the individual. | The individual plan shall be developed by an interdisciplinary team, including the following: The individual. | Violation 183 (a) (1) has been corrected. See POC # 8. This was a result of an oversight on SC; however, Provider will ensure all documentation be reviewed by Program Specialist on the day of meetings to avoid these issues as well as proper follow ups with SC's if necessary. |
04/24/2025
| Implemented |