| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | The kitchen counter had knife cuts in its surface and this same area had a worn-out look from excessive cleaning. | Floors, walls, ceilings and other surfaces shall be in good repair. | The counter top has been replaced.
Agency has revised both Monthly Home Inspection form completed by House Manager/APD monthly and Bi- annual Safety Inspection checklist completed by Safety Committee member/PD/RD 2 x per year to ensure floors, walls and ceilings will be maintained in each home.
Beth Davidson will email documentation to BHSL . |
01/31/2017
| Implemented |
| 6400.141(c)(7) | The physical examination for individual #1 dated 5/29/15, date of admission 12/01/15, did not have a completed gynecological examination until 4/21/16. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Individual # 1 was an emergency admission and had never had a Gyn exam completed while living at home with family as they believed it was too stressful. Agency is in the process of applying for a waiver of this regulations for all emergency admissions and requesting that we have120 days from admission to complete. |
03/11/2017
| Implemented |
| 6400.141(c)(8) | Individual # 1, date of admission 12/01/15, did not have a mammogram until 1/5/16. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | Individual # 1 was an emergency admission and her mammogram was 3 years ago previously. Agency is in the process of applying for a waiver of this regulations for all emergency admissions and requesting that we have 120 days from admission to complete. |
03/11/2017
| Implemented |
| 6400.142(a) | Individual # 1 did not complete the dental examination until 1/28/16. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Individual # 1 was an emergency admission and had not had any dental work completed in several years. Agency is in the process of applying for a waiver of this regulations for all emergency admissions and requesting that we have 120 days from admission to complete. |
03/11/2017
| Implemented |
| 6400.181(e)(12) | The assessments dated 1/26/16 and 5/10/16 did not have specific recommendatons for individual #1 | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Agency has revised their Assessment guide so it provides more details about what is needed by regulation in each section of the assessment. The guide also provides guidelines on how to document progress/growth and/or regression. Beth Davidson will forward to BHSL via email revised form and completed assessments using the new guidelines to show compliance. |
01/31/2017
| Implemented |