| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.111(c)(1) | The section for previous medical history on the physical dated 12/5/24 for Individual #1 noted to see attached for the information. There was no attachment to illustrate the information that had been reviewed. | The physical examination shall include: A review of previous medical history. | Medical History was attached to the physical |
12/10/2024
| Implemented |
| 2380.111(c)(3) | The physical dated 9/26/24 for Individual #3 noted a date for the Tdap immunization required every ten years as 8/15/14. There was no additional information available to indicate that an updated immunization was completed by 8/15/24 as required. | The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Program Specialist reached out to ICF Nursing and TDAP was completed |
12/10/2024
| Implemented |
| 2380.111(c)(10) | The section for medical information pertinent to diagnosis and treatment in case of an emergency was blank on the physical dated 12/5/24 for Individual #1. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Program Specialist reached out to provider to get this information |
12/10/2024
| Implemented |
| 2380.132(9) | The freezer temperature log for 2024 maintained on the freezer door by the provider indicates that of the 143 daily temperature checks the temperature was maintained at or below zero 40 of those days as of 12/9/24. Frozen food shall be kept at or below 0°F. | If the facility provides or arranges for meals for individuals, the following requirements apply: Cold food shall be kept at or below 45°F. Hot food shall be kept at or above 140°F. Frozen food shall be kept at or below 0°F. | Staff will check the freezer temperature first thing in the morning to ensure it is accurate. |
12/10/2024
| Implemented |
| 2380.181(a) | Individual #1 has a documented admission date of 7/1/24. The assessment in the record of Individual #1 was dated as completed on 9/30/24. This is outside of the 60 days provided to complete the assessment. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. | Program Specialist completed a "New Admissions" checklist to include when the assessment should be completed. |
12/10/2024
| Implemented |
| 2380.38(b)(5) | There was no documentation to support that Staff #1 had orientation training on the Individual Support Plans (ISPs) for Individual #1 and Individual #2.
There was no documentation to support that Staff #2 had orientation training on the ISP for Individual #1.
The "job-related knowledge and skills" orientation required must include all knowledge and skills necessary for the health, safety, and welfare of the specific individuals served, such information is included in the ISP. | The orientation must encompass the following areas: Job-related knowledge and skills. | Current staff list was created to make sure all staff are signing off on ISP's. |
12/10/2024
| Implemented |
| 2380.181(f) | There was no documentation to support that the assessments for Individual #1 and Individual #2 had been provided to the individual plan team members at least 30 calendar days prior to the individual plan meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting. | Letters were sent to plan team members |
12/10/2024
| Implemented |