| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency did not compete a self-assessment of the home within 3-6 months of the expiration of the license. The agency completed the assessment of the home between 8/1/23 and 9/12/23. The agency's license expires on 10/1/23. | 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.
| Self-assessments will be completed by the Supervisor/Associate Director/Director during the following months in 2023 and 2024 - November 2023, March and June 2024 to allow for the successful compliance of this regulation. |
10/24/2023
| Implemented |
| 6400.22(d)(1) | The provider does not maintain an up to date financial record for individual #1. Individual #1's assessment indicates that Individual #1 can manage $20. There is no financial record maintained for any purchases over $20 prior to August 2023. The financial record maintained in the home was accurate based on the starting and ending balances, however, Individual #1 had $5 too much based on an accounting of the money and checks that were present in the home. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | A "Program-Participant-Petty-Cash-Daily-Account-Form has been initiated and will be maintained by all DSP's. The Program Supervisor will continue to review for accuracy on a weekly basis. |
10/26/2023
| Implemented |
| 6400.141(a) | Individual #1 did not have an annual physical exam completed in 2023. Individual #1's most recent annual physical examination was competed on 8/23/22. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #1 had a physical conducted on 9/28/2023. The program supervisor will ensure a physical is scheduled and attended no later than 9/28/2024. |
10/26/2023
| Implemented |
| 6400.52(c)(1) | Staff #1 did not receive annual training in the 2022 training calendar year in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. The provider's training calendar year runs from July 1 to June 30. Staff #1 did not receive annual training in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships until 7/5/23. | 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. | This annual training has been scheduled through the College of Direct Support" and incorporates the required trainings listed above. |
10/26/2023
| Implemented |
| 6400.52(c)(3) | Staff #1 did not receive annual training in the 2022 training calendar year in Individual Rights. The provider's training calendar year runs from July 1 to June 30. Staff #1 did not receive annual training in Individual Rights until 7/5/23. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | This annual training has been scheduled through the College of Direct Support" and incorporates the required training listed above. |
10/26/2023
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medications to treat symptoms of psychiatric illness. Individual #1 had a late review of medications to treat mental health issues. Individual #1 had a review of medications to treat symptoms of psychiatric illness on September 23, 2022, and did not have another review until January 5, 2023. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Individual #1 had a medication review conducted on 9/20/2023. The program supervisor will ensure a medication review is scheduled and attended no later than 12/20/2023. |
10/26/2023
| Implemented |
| 6400.185(1) | Individual #1's Individual Service Plan (ISP) does not include the strengths, functional abilities, and service needs. Individual #1's annual assessment dated 3/14/23 states that Individual #1 is able to manage $20. Individual #1's ISP does not include the individual's ability to independently manage any amount of money. | The individual plan, including revisions, must include the following: The individual's strengths, functional abilities and service needs. | Notification to the Supports Coordinator to add the individual's ability to independently manage $20, which is the amount listed in Individual #1's assessment, to the ISP. The program Director in cooperation of the supervisor/associate director will email the documentation to ensure the correct information is added to the ISP. The Director will maintain the e-mail to recognize that this step has been completed. |
10/26/2023
| Implemented |