| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency's self-assessment completed for this site on 7/26/23, contained incomplete sections under "Individual Rights," "Staffing," Staff Health," "Plan Development/ Process/ Content," and "Home Services." Correspondingly, the following regulation items were left blank and unaddressed: .31a to .34b; .42 to .52c6; .151a to .152c; .182a to .209; .and 188a to .188d. (Repeated Violation- 1/4/22, et al.) | 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.
| A training was conducted with the program specialists on the proper completion of the self-assessment to include the agency policy, and the importance of documentation of steps taken to correct any violations. this was completed on 12/12/2023 |
12/12/2023
| Implemented |
| 6400.106 | This home had a furnace inspection and cleaning completed 8/23/22 and then again on 9/26/23. (Repeated Violation- 1/4/22, et al.) | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| A monthly checklist of required duties has been created for program specialists to include scheduling furnace inspections for a date on or prior to the previous inspection. |
12/04/2023
| Implemented |
| 6400.141(c)(3) | Individual #1's date-of-birth is 12/4/77. Individual #1's physical examination completed on 7/13/23, contained an incomplete list of their immunization record. The physical examination form documented only their tetanus/ diphtheria vaccinations given on 5/24/16 and did not provide reference to or include an attached, comprehensive immunization record. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Site monitors reviewed the importance of ensuring that all sections of appointment documentation are completed in their meeting on 12/21/2023. |
12/21/2023
| Implemented |
| 6400.181(e)(13)(i) | Individual #1's assessment completed on 1/5/23 did not address the skill progression over the last 365 days in the area of health. Individual #1's 1/5/23 assessment only addressed their current level of functioning in the above skills area. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| Program specialists were trained on the proper completion of program assessments on 12/07/2023. the training included the importance of completing all sections with complete sentences and addressing all prompts with detailed information regarding the individuals current level of functioning as well as progress over the last year. |
12/07/2023
| Implemented |
| 6400.181(e)(13)(ii) | Individual #1's assessment completed on 1/5/23 did not address the skill progression over the last 365 days in the area of motor and communication skills. Individual #1's 1/5/23 assessment only addressed their current level of functioning in the above skills area. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | Program specialists were trained on the proper completion of program assessments on 12/07/2023. the training included the importance of completing all sections with complete sentences and addressing all prompts with detailed information regarding the individuals current level of functioning as well as progress over the last year. |
12/07/2023
| Implemented |
| 6400.181(e)(13)(iii) | Individual #1's assessment completed on 1/5/23 did not address the skill progression over the last 365 days in the area of activities of individual living. Individual #1's 1/5/23 assessment only addressed their current level of functioning in the above skills area. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | Program specialists were trained on the proper completion of program assessments on 12/07/2023. the training included the importance of completing all sections with complete sentences and addressing all prompts with detailed information regarding the individuals current level of functioning as well as progress over the last year. |
12/07/2023
| Implemented |
| 6400.181(e)(13)(iv) | Individual #1's assessment completed on 1/5/23 did not address the skill progression over the last 365 days in the area of personal adjustment. Individual #1's 1/5/23 assessment only addressed their current level of functioning in the above skills area. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | Program specialists were trained on the proper completion of program assessments on 12/07/2023. the training included the importance of completing all sections with complete sentences and addressing all prompts with detailed information regarding the individuals current level of functioning as well as progress over the last year. |
12/07/2023
| Implemented |
| 6400.181(e)(13)(v) | Individual #1's assessment completed on 1/5/23 did not address the skill progression over the last 365 days in the area of socialization. Individual #1's 1/5/23 assessment only addressed their current level of functioning in the above skills area. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | Program specialists were trained on the proper completion of program assessments on 12/07/2023. the training included the importance of completing all sections with complete sentences and addressing all prompts with detailed information regarding the individuals current level of functioning as well as progress over the last year. |
12/07/2023
| Implemented |
| 6400.181(e)(13)(vi) | Individual #1's assessment completed on 1/5/23 did not address the skill progression over the last 365 days in the area of recreation. Individual #1's 1/5/23 assessment only addressed their current level of functioning in the above skills area. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | Program specialists were trained on the proper completion of program assessments on 12/07/2023. the training included the importance of completing all sections with complete sentences and addressing all prompts with detailed information regarding the individuals current level of functioning as well as progress over the last year. |
12/07/2023
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's assessment completed on 1/5/23 did not address the skill progression over the last 365 days in the area of financial independence. Individual #1's 1/5/23 assessment only addressed their current level of functioning in the above skills area. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| Program specialists were trained on the proper completion of program assessments on 12/07/2023. the training included the importance of completing all sections with complete sentences and addressing all prompts with detailed information regarding the individuals current level of functioning as well as progress over the last year. |
12/07/2023
| Implemented |
| 6400.181(e)(13)(viii) | Individual #1's assessment completed on 1/5/23 did not address the skill progression over the last 365 days in the area of managing personal property. Individual #1's 1/5/23 assessment only addressed their current level of functioning in the above skills area. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | Program specialists were trained on the proper completion of program assessments on 12/07/2023. the training included the importance of completing all sections with complete sentences and addressing all prompts with detailed information regarding the individuals current level of functioning as well as progress over the last year. |
12/07/2023
| Implemented |
| 6400.181(e)(13)(ix) | Individual #1's assessment completed on 1/5/23 did not address the skill progression over the last 365 days in the area of community integration. Individual #1's 1/5/23 assessment only addressed their current level of functioning in the above skills area. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community integration. | Program specialists were trained on the proper completion of program assessments on 12/07/2023. the training included the importance of completing all sections with complete sentences and addressing all prompts with detailed information regarding the individuals current level of functioning as well as progress over the last year. |
12/07/2023
| Implemented |