| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The Annual Self Inspection document completed 02/27/25 did not include a review of regulations 6400.14b -- 6400.31c. | 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.
| The Residential Administrative Team, and the Compliance Department involved in completing a self-assessments will be retrained by 6/15/2025 on the full scope of regulations required in the self-assessment process. Emphasis will be placed on the need to include all regulatory areas listed in Chapter 6400, ensuring no sections are omitted. |
06/15/2025
| Implemented |
| 6400.68(b) | At the time of the 04/30/25 inspection, the hot water temperature at every tested hot water source was 123.2 degrees Fahrenheit. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | On 4/30/2025 at the time of the inspection, the Residential Director lowered the temperature on the hot water tank. The maintenance department completed daily checks since to ensure the temperature is within regulation. |
04/30/2025
| Implemented |
| 6400.141(c)(13) | The 04/02/25 Annual Physical form states that individual #1 is allergic to ibuprofen, however, other documents in the record state that Individual #1 has no allergies. | The physical examination shall include: Allergies or contraindicated medications. | On 5/7/2025, the inconsistency in allergy documentation was reviewed with the prescribing physician. A clarification was obtained and documented.
All medical records were updated to reflect the accurate allergy status of Individual #1. |
05/07/2025
| Implemented |
| 6400.141(c)(14) | The 04/02/25 Annual Physical form does not include information pertinent to treat/diagnose in the event of an emergency, however, Individual #1 has pertinent information as described in the record. (Repeat Violation from 04/30/24) | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | On 5/5/2025, the individual's physician was contacted to complete the missing emergency medical information section on the 02/25/25 physical form. The updated physical with the completed section has been obtained and placed in the individual's record. |
05/05/2025
| Implemented |
| 6400.181(e)(1) | The current 09/12/24 Annual Assessment does not list Individual #1 "preferences". (Repeat Violation from 04/30/24) | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | On 5/12/2025, the assessment for Individual #1 was revised to include a detailed summary of their preferences related to daily routines, food, activities, communication, social interactions, and community engagement. The revised assessment was reviewed and signed by the individual, their team, and filed in their record. |
05/12/2025
| Implemented |
| 6400.181(e)(7) | The current 09/12/24 Annual Assessment does not fully describe if Individual #1 can independently move away quickly from heat sources or what level of supervision is needed. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | On 5/12/2025, the assessment was updated to include a thorough evaluation of Individual #1's ability to recognize the danger of hot surfaces, their sensory awareness, and their capacity to move away from heat sources that exceed 120°F. The updated assessment also clearly documents the level of supervision required when the individual is near potential heat sources such as stoves, radiators, or water above 120°F. The Program Specialist completed a retraining of the specific requirements outlined in the Regulations for Assessments. |
05/12/2025
| Implemented |
| 6400.165(g) | The 03/03/25 quarterly psychiatric medication review does not include the name or dosage of the medication being reviewed. (Repeat Violation from 04/30/24) | 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. | The physician was contacted, and a revised psychiatric medication review for Individual #1 was obtained on 5/13/2025. The updated review includes a full list of all prescribed psychiatric medications, dosages, and the reason for each medication, as well as justification for continuation and dosage levels. The revised review has been filed in the individual's record. |
05/13/2025
| Implemented |
| 6400.181(f) | There is a document in the record that indicates that the Annual Assessment was sent to the Individual Support Plan (ISP) team, but there is no date on the document to establish when it was sent. (Repeat Violation from 04/30/24) | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The Program Specialists was retrained on 5/8/2025 on the requirements of 6400.181 (f) which included the necessity to send the assessment to all ISP team members at least 30 days prior to the ISP meeting. The requirement to clearly date all records of transmission. |
05/08/2025
| Implemented |