| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | The wall of the living room above the chair rail has several large notable areas of abrasions from chairs rubbing and hitting the wall that require painting. | Floors, walls, ceilings and other surfaces shall be in good repair. | GH maintenance supervisor contacted and scheduled with a contracted painter to paint the interior of Chestnut. The painting was completed as of 7/19/24 to comply with the floor, walls, ceiling and other surfaces being in good repair. |
07/19/2024
| Implemented |
| 6400.113(a) | It could not be determined if individual #1 was reinstructed annually in general fire safety. The provided record dated 10/24/2023 does not include the individual's name and/or a training list of the individual attending or who conducted the training. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | Group Home Supervisor corrected/updated Individual#1's annual fire safety documentation to include the date of the training, the individual's name and the trainer's name in order to document annual training in the area for general fire safety, evacuation procedure, responsibilities, and meeting place in the event of an actual fire. This was completed on 7/3/24. |
07/09/2024
| Implemented |
| 6400.141(a) | Individual #1 did not have a physical examination completed annually. The previous exam was completed 02/13/2023 and the most recent physical exam was completed 03/19/2024. This exceeds the timeframe of the annual requirement. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Direct Support Supervisor contacted Individual#1's primary care doctor and scheduled annual physical for March 17, 2025 to ensure that annual physical examination is within 12 months prior to admission and annually thereafter. |
08/09/2024
| Implemented |
| 6400.181(e)(12) | Recommendations for specific areas of training, programming and services where not included on the annual assessment for individual #1. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The Qualified Professional for individual#1 met with the team on 7/12/24 to review the assessment area that addresses specific area of training, programming and services. Suggestions were agreed upon and added to individual#1's assessment.
Lead Qualified Professional provided training to QP team on 7/9/24 to ensure that this area is completed correctly in the assessment. |
07/12/2024
| Implemented |
| 6400.34(b) | The agency failed to provide signed documentation that Individual #1 or the individual's appointed guardian was informed and /or explained annually of their individual rights. The form provided does not have a signature and is dated 10/24/2023. | The home shall keep a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights. | QP met with Individual#1 mother to review with her and individual#1 the individual rights policy. The document was reviewed and dated on 7/12/24 to acknowledge receipt of information on individual rights. |
07/12/2024
| Implemented |