| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency's self-assessment windows of completion are the following: 5/23/24 to 8/3/24 and/or 3/28/24 to 6/28/24. The home's self-assessment was completed on 8/30/24. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| CLASS Quality and Compliance Coordinator (QCC) will complete quarterly self-assessments of houses. Residential house managers (RHM) will complete monthly house inspections. The self-assessment windows will be placed on the corporate calendar for continuity of completion and to ensure that dates are being met. |
12/31/2024
| Implemented |
| 6400.15(c) | The agency completed the self-assessment completed on 8/30/24, identifying the following violations: .80a, .112, and .113. However, no written summary of corrections was provided. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| CLASS Quality and Compliance Coordinator (QCC) will complete quarterly self-assessments of houses. Any identified violations will be corrected and a new self-assessment will be completed showing compliance. Self assessments will be kept for at least one year. |
12/31/2024
| Implemented |
| 6400.64(e) | On 9/26/24 at 11:15 AM, a trash receptacle measuring one foot, six inches in height was observed without a lid in the home's first-floor bathroom. | Trash receptacles over 18 inches high shall have lids. | Garbage cans have been replaced with ones that are under 18 inches high. |
12/31/2024
| Implemented |
| 6400.64(f) | On 9/26/24 at 10:41 AM, two outdoor trash receptacles were found with full, white trash bags protruding from the top, preventing the lids from being closed. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | Additional Outdoor trash cans were ordered. |
12/31/2024
| Implemented |
| 6400.112(c) | The home does not have a written record of fire drills conducted from October 2023 to August 2024. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Residential homes managers were all retrained on the regulations pertaining to fire drills. Fire drill log forms were updated and reviewed with all residential homes managers on 10/3/2024. |
12/31/2024
| Implemented |
| 6400.113(a) | Individual #1 was trained in fire safety on 5/30/23, and then again on 6/26/24. | 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. | CLASS Quality and Compliance Coordinator (QCC) will complete quarterly self-assessments of houses. Any identified violations will be corrected and a new self-assessment will be completed showing compliance. Individual #1 had fire safety training on 6/26/2024. Program Specialists were retrained on timeframes and grace periods for annual paperwork. |
12/31/2024
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination completed on 9/12/24, did not address medical information pertinent to diagnosis and treatment in case of an emergency. This field was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Residential homes managers were all retrained on the regulations pertaining to time frames and required documentation with scheduling medical appointments. |
12/31/2024
| Implemented |
| 6400.151(a) | Direct Support Professional #1's most recent physical examination was completed on 10/2/21. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | DSP completed annual physical on 10/14/2024 |
12/31/2024
| Implemented |
| 6400.181(e)(1) | Individual #1's assessment, completed on 5/3/24, did not include their functional strengths, needs, and preferences. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | CLASS annual assessment has been revised to add Functional strengths, needs and preferences of the individual. |
12/31/2024
| Implemented |
| 6400.34(a) | Individual rights were reviewed and explained to Individual #1 on 6/14/23, and then again on 6/24/24. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Program Specialists were retrained on timeframes and grace periods for annual paperwork. |
12/31/2024
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medications to treat symptoms of a psychiatric illness. They had a medication review completed by a licensed physician completed on 3/20/24, and then again on 7/2/24. Additionally, Individual #1 had medication reviews completed on the following dates: 9/8/23, 12/7/23, 3/20/24, 7/2/24, and 9/12/24. However, all of these medication reviews did not include a reason for prescribing the following medications: Amlodipine 5mg, Aspercreme 10% topical cream, Asprin EC 81mg, and Calcium Carbonate 200mg. | 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. | Residential homes managers were all retrained on the regulations pertaining to time frames with scheduling medical appointments. Residential homes managers were retrained on forms that need completed and accurate documentation pertaining to prescribed medications. |
12/31/2024
| Implemented |
| 6400.166(a)(7) | On 9/26/24 at 10:52 AM, during a medication administration review, Individual #1's September 2024 Medication Administration Record read as follows: Paroxetine HCL 40mg---Take 1 tablet by mouth every day. However, the medication label for the prescribed Paroxetine HCL 40 mg differed from Individual #1's September 2024 Medication Administration Record regarding the proper dosage as it read as follows: Take 1 tablet by mouth daily in addition to 10 mg Paxil. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | Program Specialist and Residential home manager have made corrections to the medication administration record to ensure that it matches the physician¿s orders and the medication label. |
12/31/2024
| Implemented |
| 6400.182(c) | Individual #1's assessment completed on 5/3/24 indicates that staff prepare medications as prescribed and that they do not self-medicate. However, their Individual Support Plan, last updated on 9/16/24, explains Individual #1 self-medicates with minimal verbal reminders/physical assistance. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Program Specialist reached out to Support Coordinator to make corrections to ISP. ISP has been updated to reflect correct need. |
12/31/2024
| Implemented |