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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.21(u) | Individual #1 was informed of their individual rights and the process to report a rights violation on 6/21/2022 and then again on 1/13/2024. This exceeds the annual requirement. Individual #2 was informed of their individual rights and the process to report a rights violation on 8/14/2023 then again 8/20/2024. This exceeds the annual requirement. | The facility 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 facility and annually thereafter. | The Program Specialist was retrained on this regulation on 1/21/25. Additionally, the agency reached out to individual #1¿s home and the individual rights signed form was turned in on 1/20/25 and dated 1/13/25. For individual #2, their annual date has been updated to 8/20/25. [Training documentation for Program Specialists, which was not dated and did not indicate training content, was provided to the Department on 5/19/25 and review 5/29/25. A Post-It Note states that the training was completed 1/21/25. Individual Rights document for Individual #1, dated 1/7/25, was received on 5/19/25 and reviewed 5/29/25. Tracking document for Individual #2 related to individual rights was received on 5/19/25 and reviewed 5/29/25. A blank letter template for notification of individual rights coming due was received on 5/19/25 and reviewed 5/29/25. DPOC by HDKP, HSLS, on 5/29/25.] |
01/21/2025
| Implemented |
| 2380.182(c) | Individual #2's individual support plan, last updated 12/03/2024, does not address the individual's knowledge of the danger of heat sources and ability to sense and move away quickly. Individual #2's assessment completed 3/19/2024, states Individual #2 needs verbal prompts regarding knowledge of the danger of heat sources and ability to sense and move away quickly. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The individual¿s assessment has been updated to reflect the correct response per the ISP. Additionally, the Program Specialist was trained on 1/21/25 that moving forward, if the ISP does not provide an appropriate response, we will request the SC to update the plan. They were also retrained on the regulation. [An updated page of the assessment for Individual #2, with undated changes made to the assessment, was received on 5/19/25 and reviewed 5/29/25. Training documentation for Program Specialists, which was not dated and did not indicate training content, was provided to the Department on 5/19/25 and review 5/29/25. A Post-It Note states that the training was completed 1/21/25. DPOC by HSKP, HSLS, on 5/29/25.] |
01/21/2025
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.111(c)(4) | Individual #1's annual physical examination, completed on 12/6/2023, did not include a hearing screening. This section was left blank. Individual #2's annual physical examination, completed on 9/1/2023, did not include vision and hearing screenings. The Primary Care Physician noted that individual #2 should follow-up with specialists; however, no documentation of these examinations could be provided by the agency. Individual #3's annual physical examination, completed on 7/27/2023, did not include a vision screening. The Primary Care Physician noted that individual #3 is followed by an optometrist; however, documentation of this examination could not be provided by the agency. | The physical examination shall include: Vision and hearing screening, as recommended by the physician. | On 1/26/24, the Program Specialist contacted the caregiver for individual #1 to request that the physical exam be completed in its entirety, or to provide missing information in the form of documentation.
For individual #2 ¿ on 1/26/24 documentation from follow up specialist has been requested by the Program Specialist to caregiver.
For individual #3 ¿ on 1/26/24 documentation from the optometrist has been requested by the Assistant Director. Assistant director contacted individual #3s residential provider. |
01/26/2024
| Implemented |
| 2380.111(c)(10) | Individual #3's annual physical examination, completed on 7/27/2023, did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Following inspection, on 1/26/24, the Program Specialist requested residential provider that a physical form be completed in its entirety, which includes the section about medical information being pertinent to diagnosis and treatment in case of emergency. |
01/26/2024
| Implemented |
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