| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.110(b) | On 2/20/25, at 11:45 AM, there was no operable automatic smoke detector located within fifteen feet outside of individual #1's bedroom door. | There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. | On February 25, 2025, Maintenance Personnel installed a smoke detector on the ceiling in the hallway outside of the bedrooms. They ensured that it is within 15 feet of the bedroom doors. All other homes were checked to ensure smoke detectors are within 15 feet of each bedroom door. |
03/03/2025
| Implemented |
| 6400.216(a) | On 2/20/25, at 11:50 AM, hard copies of Individual #1's Individual Support Plan, last updated on 11/15/23, and Restrictive Procedure Plan, last updated on 1/4/24, were laying in plain view, unlocked and accessible on top of the entertainment center located underneath the tv in the home's living room. | An individual's records shall be kept locked when unattended.
| Program Director conducted a retraining with the Assistant Program Manager on 3/3/25 for violating regulation 216a, which states that an individuals record shall be kept locked when unattended. |
03/03/2025
| Implemented |
| 6400.32(r)(1) | On 2/20/25, at 11:49am, the door lock to Individual #1's bedroom was equipped with a pop lock on the inside and a push-pinhole access point on the entry side. Individual #1 does not have an entry mechanism to lock and unlock their bedroom door. | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | On 3/3/25 during the individual training for the new lock, Individual #1 stated that s/he did not want a lock on their bedroom door. Individual #1 guardian was present and agreed that they did not feel that s/he needed a lock on their bedroom door. Signatures were obtained from the individual and their guardian declining a lock on their bedroom door. The individual and their guardian were informed that they have the right to change their mind at any time and AMA Support Services would install a lock of his choosing on Individual #1 bedroom door. |
03/03/2025
| Implemented |
| 6400.32(r)(4) | On 2/20/25, at 11:49 AM, the door lock to Individual #1's bedroom was equipped with a pop lock on the inside and a push-pinhole access point on the entry side. This bedroom door lock mechanism does not allow easy and immediate access by the individual and staff persons in the event of an emergency. | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. | On 3/3/25 during the individual training for the new lock, the individual stated that they did not want a lock on their bedroom door. Their guardian was present and agreed that they did not feel that Individual #1 needed a lock on their bedroom door. Signatures were obtained from the individual and their guardian declining a lock on their bedroom door. The individual and their guardian were informed that they have the right to change their mind at any time and AMA Support Services would install a lock of his choosing on his bedroom door. |
03/03/2025
| Implemented |
| 6400.166(d) | On 2/20/25, Individual #1's February 2025 Medication Administration Record indicates that the prescribed medication Baclofen 5 MG Tablet was administered at the incorrect time of 2 AM from 2/1/25 through and including 2/16/25. The correct administration times are 8 AM, 2 PM, and 8 PM. | The directions of the prescriber shall be followed. | A medication review was conducted on 2/15/24 by the Program Manager. Program Manager realized that the time for the Baclofen 5 mg had been entered incorrectly. The Program Manager discontinued the incorrect entry and made another entry ensuring that the new entry listed the correct medication, correct administration times, dosage and route for the individual. Staff were retrained on the 5 rights required for administering medications. |
03/05/2025
| Implemented |
| 6400.182(c) | Individual #1's Individual Support Plan, last updated on 1/15/25, was not revised to reflect their current needs as based on their current assessment, completed on 7/16/24, in the following health and safety skill domains: regarding poisonous materials, Individual #1's Individual Support Plan stated they are unaware of such substances, that they require supervision in the form of hands-on physical assistance to safely use these materials, and that such materials are kept locked at the home. However, Individual #1's assessment provided a "Score of 3," meaning they require minimal support that "could include verbal prompting, gestures, reminders, etc." to identify and use poisonous materials safely, and that such materials are kept locked at the home. The type of supervision of hands-on physical assistance to safely use poisonous substances was not indicated; and regarding non-insulated heat sources exceeding 120 degrees Fahrenheit, Individual #1's Individual Support Plan explained that they require complete physical assistance and supervision when around such sources. However, Individual #1's assessment provided a "Score of 4," indicating that they can independently sense and quickly move away from dangerous heat sources. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The information documented in the assessment was entered incorrectly. On 3/4/25 the Program Manager entered the correct information on the assessment and sent the assessment to the individuals SC. |
03/04/2025
| Implemented |