| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self-assessment for the home completed on 11/18/22 did not assess compliance with the following regulations: 6400.186 and 6400.213(1)v. | 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.
| Associate Directors of Operations and the Director of Operations shall standardize the annual self-assessment process, including assigning point people to ensure that all self-assessment items are marked appropriately. |
10/01/2023
| Implemented |
| 6400.15(c) | (Repeated Violation -- 7/11/22) The self-assessment for the home completed on 11/18/22 did not include a written summary of corrections for the following violations: 6400.46d, 6400.142a, and 6400.144. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| Director of Operations and Associate Directors of Operations will model after RCG guide to follow the five steps and instruct point people to write an effective Plan of Correction and focus on prevention of citations by 9/1/23. |
10/01/2023
| Implemented |
| 6400.22(c) | On 3/23/23 Individual #1 purchased incontinence items for $16.34 at Walmart with personal funds. Individual #1 is not responsible for purchasing this item. | Individual funds and property shall be used for the individual's benefit. | Friendship Community stated a certified investigation of exploitation for individual #1 on 7/5/23. Friendship Community reimburse individual #1 funds on 7/6/23. |
10/01/2023
| Implemented |
| 6400.67(a) | In the basement area, there were 2.5 ceiling tiles missing at the time of the 7/6/23 inspection. | Floors, walls, ceilings and other surfaces shall be in good repair. | Ceiling tiles were replaced on 7/18/2023. |
10/01/2023
| Implemented |
| 6400.112(a) | (Repeated Violation -- 7/11/22) There was not a fire drill conducted at the home in May 2023. | An unannounced fire drill shall be held at least once a month. | Associate Directors of Operations will educate Residential Managers and Coordinators overseeing the residential homes on the expectations surrounding monthly fire drills by 8/15/23. |
10/01/2023
| Implemented |
| 6400.181(e)(3)(iv) | Individual #1 was injured in a car accident 2/20/23 and required surgery, rehab & PT when returning home. Individual #1 required a use of a back brace, walker & cane to assist with ambulation. This information was not updated in the assessment and distributed to team members. The annual assessment that is in the record is dated 8/16/22. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal needs with or without assistance from others. | Associate Director of Operations will educate the Program Specialists on the assessment instrument tool and when to initiate an assessment addendum when an individual's needs level changes on 8/15/2023. |
10/01/2023
| Implemented |
| 6400.18(a)(12) | On 3/23/23, Individual #1 purchased Assurance 36, which is an incontinence product, for $16.34 with their personal funds. The agency's fiscal department was aware of this purchase, however, an incident was not filed in the Department's incident management system. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Theft or misuse of individual funds. | Friendship Community stated a certified investigation of exploitation for individual #1 on 7/5/23. Friendship Community reimburse individual #1 funds on 7/6/23. Friendship Community completed the certified investigation on 8/1/23. |
10/01/2023
| Implemented |