| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency's self-assessment windows of completion are the following: 5/23/24 to 8/3/24 and/or 3/28/24 to 6/28/24. The home's self-assessment was completed on 9/9/24. | 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.
| CLASS Quality and Compliance Coordinator (QCC) will complete quarterly self-assessments of houses. Residential house managers (RHM) will complete monthly house inspections. The self-assessment windows will be placed on the corporate calendar for continuity of completion and to ensure that dates are being met. |
12/31/2024
| Implemented |
| 6400.15(c) | The home's self-assessment completed on 9/9/24, identified the following violations: .20b for not completing quarterly incident reviews; .34a for an unidentified individual signing their rights late; and .165g for missing three-month psychiatric medication reviews for all three individuals in home. However, the agency did not provide a corresponding written summary of corrections for each violation. | 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.
| Self licensing follow up was completed on 10/17/2024. Review of incidents was completed on 10/22/2024 and quarterly review meetings were scheudled on the corporate calendar for continuity of completion if there are staff changes. |
12/31/2024
| Implemented |
| 6400.112(e) | The home's written fire drill record submitted from October 2023 to August 2024, documented that the only fire drill held during sleeping hours was conducted on 7/6/24. | A fire drill shall be held during sleeping hours at least every 6 months. | Residential homes managers were all retrained on the regulations pertaining to fire drills. Fire drill log forms were updated and reviewed with all residential homes managers on 10/3/2024. |
12/31/2024
| Implemented |
| 6400.216(a) | On 9/26/24 at 12:20 PM, Individual #1's white binder of personal, medical, and programming records was found unlocked and unsecured on an open shelf of a hutch located in the home's dining room. | An individual's records shall be kept locked when unattended.
| Individual records will be kept locked up when not in use. All residential homes managers were retrained on this procedure. |
12/31/2024
| Implemented |
| 6400.52(c)(6) | Program Specialist/ Quality Control Specialist #1 did not include documentation showing completion of annual training for the 2023-2024 fiscal training year regarding the required content on the implementation of the Individual Support Plan(s). | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | Program Specialist has completed training on each individual she has worked with. |
12/31/2024
| Implemented |
| 6400.169(a) | Direct Support Professional #2 successfully completed the Department-approved medication administration course on 1/4/23, and then again on 6/24/24. On 9/25/24, Quality and Compliance Coordinator #3 revealed that Direct Support Professional passes medications with regularity at this home. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | Direct Support Professional #2 will complete medication retraining and have medication pass observations completed by 11/31/2024 |
12/31/2024
| Implemented |