| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(2) | The financial record for individual 4 indicated on 11.18.2023, that individual 4 had a receipt for $35 for wash blow dry and curl. However, there is nothing on the ledger to indicate where this comes from | (2) Disbursements made to or for the individual.
| Program Managers will be retrained on the requirement to have a receipt for all purchases above $15.00. |
05/23/2024
| Implemented |
| 6400.22(e)(1) | There were no bank statements provided for individual 4 during inspection. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. | During the period of review, there was not a bank account created for this individual. Bancroft is currently in the process of creating bank accounts with fulton bank to provide every individual with their own account. |
06/30/2024
| Implemented |
| 6400.43(b)(1) | Policies and procedures regarding locked doors were not updated in the individual records | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | The Program Manager will review any locked doors in the home and ensure that these are added into the individuals ISP and assessment. |
05/23/2024
| Implemented |
| 6400.68(b) | The water temp was 138 in second floor personal bathroom and 140 in the kitchen sink. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Facilities was contacted on 12/15/2023 regarding the water temperature. Water temperature was adjusted to not exceed 120 degrees. |
12/15/2023
| Implemented |
| 6400.113(a) | There was no record to indicate individual 4 received a Fire safety training produced during inspection. | 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. | Program Managers will be retrained on completing the fire safety training for their individuals and filing them in the individual's program book. |
05/23/2024
| Implemented |
| 6400.144 | Physical for calendar year 2022, was completed 1.13.2022; and the. physical completed in 2023, was completed 4.19.23, and was three months late. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Bancroft hired an additional LPN to increase the nursing departments staffing to support with appointment scheduling to ensure all appointments remain in compliance and are completed within the required timeframe. |
05/20/2024
| Implemented |
| 6400.181(a) | Annual assessment was not completed timely for individual 4. Dates of completion are 1.18.22 and May 3, 2023 | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Program Managers will be retrained on the required timeframe for initial and annual assessments. |
05/23/2024
| Implemented |
| 6400.181(e)(7) | Assessment does not speak to the individual's direct knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. The assessment stipulates client is able to identify fire and smoke detector. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | Program Managers will be retrained on the required information regarding the individual's direct knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulate for the initial and annual assessments. This individual's assessment is being updated with their upcoming ISP. |
05/31/2024
| Implemented |
| 6400.165(g) | Only 2 psychotropic medication reviews for individual 4 were provided for individual 4 were on 8.14.23 and 11.13.23. | 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. | Bancroft has been in communication with the psychiatric provider regarding the need to receive all consultation forms back. Bancroft is currently in the process of identifying another provider for our individuals. |
04/17/2024
| Implemented |
| 6400.181(f) | ISP invitation letter for individual 4 was not in their record. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Program Managers will be retrained on the requirement to have and file the ISP invitation letter. |
05/23/2024
| Implemented |