| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | A single use packet of a 500mg Tylenol was unlocked and accessible in the first aid kit in a drawer in the living room on the first floor of the home. Individual #2 is not assessed safe around poisons. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The single use packet of 500 mg Tylenol was immediately removed from the first aid kit and and secured in a locked area. |
09/01/2023
| Implemented |
| 6400.141(c)(4) | Individual #1's physical examination, completed 2/28/23 did not include a vision and hearing screening. These sections were left blank. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | The program specialist has been trained on the regulation and the need to ensure that all required information is completed in full by the individual's physician. |
09/01/2023
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination, completed 2/28/23 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. | The individual's physician has been contacted to complete the medical information pertinent to diagnosis and treament in case of emergency. The program specialist has been trained on the regulation and need to ensure that all required information is completed in full by the individual's physician. |
09/01/2023
| Implemented |
| 6400.181(a) | Individual #2, date of admission 2/1/23, had an initial assessment completed 4/16/23. | 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 program specialist has been trained on the regulation and timely completion of the initial and annual updated assessment. |
09/01/2023
| Implemented |
| 6400.181(d) | Individual #1's initial assessment was dated as completed on 7/1/23; however, the program specialist signed the assessment on 7/31/23. Individual #2's initial assessment was dated as completed on 4/16/23; however, the program specialist signed the assessment on 5/2/23. | The program specialist shall sign and date the assessment. | The program specialist has been trained on the regulation and the need to sign the assessment on the date the assessment is completed. |
09/01/2023
| Implemented |