| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(c) | The fire drill record for the drill conducted on 8/26/2022 did not document the time of day that the drill occurred. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | All Fire Drill Log & Systems Checklists will now contain a Supervisors Checklist (on back of Log) in which documentation will be completed that shows areas of requirement (date, time, time intervals, evacuation time, exits, problems encountered, operable fire alarm and all documentation requested on the form is complete) are completed on the log. Each specific area will be checked off followed by the supervisors signature and date. |
12/01/2022
| Implemented |
| 6400.141(a) | The annual physical examination for Individual #5 was late; the current physical examination occurred on 3/17/2022 and the previous physical examination occurred on 2/03/2021. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The Program Supervisor will schedule upcoming Physical for individual #5 in a timely manner to ensure the next physical is obtained by 3/17/2023. |
12/01/2022
| Implemented |
| 6400.141(c)(6) | TB testing by Mantoux method for Individual #5 was late; the current TB testing occurred on 3/21/2022 and the previous testing occurred on 10/28/2019. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | The Program Supervisor will be aware of the TB testing which will be due no later than 3/21/2024. |
12/01/2022
| Implemented |
| 6400.52(c)(1) | Staff #5 did not complete the following required training during training year 7/01/2021 to 6/30/2022: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Staff #5 will complete the required training (The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships)no later than 11/11/2022. Upon completion staff#5 will notify the RES Office Coordinator to input training hours on Training Manager. |
11/11/2022
| Implemented |
| 6400.163(d) | Medications were not locked and were stored in an unlocked hall closet. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | The Community Services Administrator (CSA) informed all supervisors on 11/3/2022 to "Please relocate all medications to a locked area of the program if they are not already locked up. This is a temporary plan of correction for licensing as we work on the permanent solution. The medications must be locked regardless of the individual's safeness around poisonous substances. |
12/01/2022
| Implemented |