| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The carpet in the living room had several black stains. | Clean and sanitary conditions shall be maintained in the home. | This has been corrected. See Appendix B_G. |
03/16/2018
| Implemented |
| 6400.64(f) | Two trash cans located at the back of the residence did not have lids. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | This has been corrected. See appendix B_G. |
03/16/2018
| Implemented |
| 6400.71 | Emergency telephone numbers were not posted on or near the telephone in the living room. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| This has been corrected. See Appendix G_B |
03/16/2018
| Implemented |
| 6400.141(c)(1) | The annual physical examination dated 3/24/2017 for Individual #1 did not document that lifetime medical history was reviewed. | The physical examination shall include: A review of previous medical history. | The Nursing team was retrained on regulatory requirements. See Appendix N |
03/16/2018
| Implemented |
| 6400.141(c)(9) | The last documented prostate examination for Individual #1 was on 4/24/2014. | The physical examination shall include: A prostate examination for men 40 years of age or older. | The Nursing team was retrained on regulatory requirements. See Appendix N |
03/16/2018
| Implemented |
| 6400.142(a) | Individual #1's current annual dental exam occurred on 6/26/2017 and the previous examination occurred on 3/28/2015. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | The Nursing team was retrained on regulatory requirements. See Appendix N |
03/16/2018
| Implemented |
| 6400.144 | Docusate Sodium 100 mg. and MAPAP 325 mg. were ordered as PRN standing orders but not available in the home. | 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.
| The medication was ordered and is available in the home. Nursing will ensure that all PRN standing orders are ordered and available when appropriate |
03/16/2018
| Implemented |
| 6400.181(a) | Individual #1's most recent annual assessment was dated 10/02/2016. | 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. | The managers were retrained on this requirement. See Appendix A |
03/16/2018
| Implemented |
| 6400.184(c) | Individual #1's record did not contain a sign-in sheet for the ISP meeting that was held on 12/10/2016. | A plan team member who attends a meeting under subsection (b) shall sign and date the signature sheet. | Managers were retrained on this requirement. See Appendix A |
03/16/2018
| Implemented |