| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.111(c) | There was no Fire Extinguisher in the Kitchen during the physical site walk through. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | At the time of the inspection, the fire extinguisher was on the opposite wall of the kitchen. It was removed from the wall and placed in the kitchen, |
10/04/2024
| Implemented |
| 6400.144 | Individual # 1 has a physicians order dated 08/13/24 to D/C Cholesterol. Instead of D/C Cholesterol, the agency has not been following the physicians order and instead has been purchasing and feeding high cholesterol foods such as Jimmy Dean Breakfast Sandwiches, Chicken N Dumplings, Sloppy Joes, Mac N Cheese, Ice Cream, Hot Sausage, BBQ Ribs. These items are found on the daily menus from 08/21-31/24. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| At the time this violation was found, the PCP was contacted to get a script that had the correct cholesterol diet on it. LCSS has received that script. |
10/04/2024
| Implemented |
| 6400.213(7)(i) | Individual # 1's Demographic form last updated on 08/01/24 does not include identifying marks. The space was left blank. | Each individual's record must include the following information: A copy of the invitation to the initial ISP meeting. | Upon discovery of this violation, the demographic form was updated with an identifying mark and was distributed to the house. |
10/04/2024
| Implemented |
| 6400.32(r) | Individual # 1 was not informed of his right to lock his bedroom door. The right was not listed on the signed Individual Rights form from 07/8/24. | An individual has the right to lock the individual's bedroom door. | At the time the violation was found, LCSS updated their individual rights document to include that every individual has the right to have a lock on their bedroom door. |
10/04/2024
| Implemented |
| 6400.182(a) | Individual #1 ordered a no Cholesterol diet on 08/13/24. The current ISP dated 08/09/24 reads that he is "not prescribed any special diets". There has been no correspondence from the program specialist with the SC to update the diet as of 09/04/24. | The program specialist shall coordinate the development of the individual plan, including revisions with the individual and the individual plan team. | The supports coordinator has received an email that gives the details of this special diet that was prescribed. |
10/04/2024
| Implemented |
| 6400.195(c)(6) | Individual # 1's Restrictive Procedure plan does not include descriptions of the circumstances under which the use of physical restraints can occur. | The behavior support component of the individual plan shall include: Types of restrictive procedures that may be used and the circumstances under which the procedures may be used. | At the time this violation was found, LCSS behavior specialist reviewed all plans, including this plan, and included a description of the circumstances that the use of physical restraint can be used. |
10/04/2024
| Implemented |