| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | Drawer with no handles in individual 9's room. Baseboard heater is broken beneath front window. | Floors, walls, ceilings and other surfaces shall be in good repair. | The individual received a new dresser and the baseboard heater has been repaired |
06/16/2025
| Implemented |
| 6400.141(c)(14) | The Annual Physical Examination dated 7/10/24 for individual 8 does not address information pertinent to diagnosis in case of emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | JEVS has been working on new processes for nursing and wellness. JEVS will utilize new processes for ensuring compliance and make sure all staff is trained on these processes, which includes making sure forms are complete. |
07/17/2025
| Implemented |
| 6400.181(a) | Individual 8's date of admission is 4/24/24. The individual did not have an initial assessment until 7/12/24 which is greater than 60 days after admission. | 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. | The program specialist was counseled in this. She knows the regulations for completing timely assessments and this was an oversight on her part that should not be repeated |
06/13/2025
| Implemented |
| 6400.32(r) | There were no locks on any of the individuals' rooms in the home, however there was no documentation reflecting this. | An individual has the right to lock the individual's bedroom door. | JEVS does not agree that this individual should have a lock on their bedroom door for safety reasons. JEVS is holding team meetings about this issue. JEVS and the SC shall document the outcome in the ISP and assessment as this person cannot safely evacuate in an emergency if her bedroom door is locked
When it is determined that an individual can safely have a locked bedroom door, we will attempt to utilize keypad locks which do not require a key. This is a safer option. All team meetings and lock installations when requested will be completed by December 31, 2025. |
07/01/2025
| Implemented |
| 6400.34(a) | The signed individual rights statement for individual 8 did not include all of the rights outlined in the 6400 regulations. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | JEVS revised the individual rights form to include the list of rights as outlined in the 6400 regulations and trained all management staff on the use of the new form. |
06/16/2025
| Implemented |
| 6400.165(f) | Individual 8 is prescribed psychiatric medications, however he does not have a SEEP plan or BSP in Place. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | The behavior specialist was counseled on this issue and has since written the SEEP. |
06/20/2025
| Implemented |
| 6400.167(c) | Individual 8 did not receive their prescribed Polyethylene Glycol 3350 Powder for the dates 6/2/25 through 6/5/25 and there was no medication error entered for this medication. | A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). | A medication error was put in EIM for this incident. Incident number is 9662512 |
08/14/2025
| Implemented |
| 6400.181(f) | The annual assessment for individual 8 was sent to the team on 8/27/24 however the ISP meeting was scheduled for 8/29/24 which is less than 30 days time. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The program specialist was counseled on this. She is aware of the regulations concerning assessments and this should not be repeated |
06/16/2025
| Implemented |