| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.181(a) | Individual #1's assessment was completed 12/29/2022 and then again on 2/20/2024. This exceeds the annual requirement. | 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. | Due to agency turnover, the agency developed additional controls in the form of an individual tracking spreadsheet on 1/8/2024. Upon implementation of this form and during a review of all consumers information on 2/19/2024, the agency realized that Individual #1 had not had an updated Assessment within a year of their most recent assessment. Immediately upon discovery on 2/19/2024, the program specialist began updating Individual #1s Assessment and completed the assessment on 2/20/2024. The agency was notified of the preliminary licensing violation by the state inspector on 2/27/2024. The agency was notified of the official licensing violation by the state inspector on 3/29/2024. |
04/10/2024
| Implemented |
| 6400.34(a) | Individual #1 was informed of rights on 12/29/2022 and then again 2/19/2024. This exceeds the annual requirement. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Due to agency turnover, the agency developed additional controls in the form of an individual tracking spreadsheet on 1/8/2024. Upon implementation of this form and during a review of all consumers information on 2/19/2024, the agency realized that Individual #1 had not been informed of their individual rights within a year of their previously signed individual rights. Immediately upon discovery on 2/19/2024, Individual #1 was brought in to be informed/sign their acknowledgement of their individual rights. The agency was notified of the preliminary licensing violation by the state inspector on 2/27/2024. The agency was notified of the official licensing violation by the state inspector on 3/29/2024. |
04/10/2024
| Implemented |
| 6400.181(f) | Individual #1's assessment completed 2/20/2024 was not sent to the plan team. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Upon being notified of the preliminary licensing violation by the state inspector on 2/27/2024, the agency realized that the most recent assessment completed on 2/20/2024 had not been sent to the Individual Plan Team. The agency informed/provided a copy of the most recent Assessment during individual #1 ISP meeting on 2/26/2024. The agency was notified of the official licensing violation by the state inspector on 3/29/2024. |
04/10/2024
| Implemented |