| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | Individual #3's funds are not being used for his benefit. Individual # 3 purchased a box of baby wipes at Walmart on 1/9/2021 for $19.97. This item should not be purchased using individual's funds as it would be included in Room and Board. | Individual funds and property shall be used for the individual's benefit. | Individual #3. Individuals¿ funds were reimbursed on 4/8/2021.
See attached documentation of reimbursement. |
06/15/2021
| Implemented |
| 6400.34(a) | Individual #3 was informed of his rights on 12/24/2020. The rights haven't been updated to reflect the current Chapter 6400 regulations. The missing rights include civil and legal rights afforded by law, make choices and accept risks, refuse to participate in activities and services, control their own schedule and activities, choice of roommate, furnish/decorate bedroom and common areas, lock bedroom door, a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door, access to an individual's bedroom shall be provided only in a life-safety emergency or with the express permission of the individual for each incidence of access, assistive technology shall be provided as needed to allow the individual to lock and unlock the door without assistance, locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency, primary caregiver shall have the key or entry device to lock and unlock the door entry mechanism to lock/unlock the front door, access to food, make health care decisions. | 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. | Threshold will review and update the Rights Statement and Policy regarding individuals¿ rights by 4/14/2021.
Updated rights review for Individual #3 is attached. |
06/15/2021
| Implemented |
| 6400.46(b) | Staff #1 had annual fire safety training on 1/24/2020 and not again until 2/20/2021. This exceeds the annual requirement. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Program Specialist will ensure that all staff are trained on Fire Safety within the time frame and annually. |
06/15/2021
| Implemented |
| 6400.52(c)(1) | 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. | 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. | Staff #1 will receive the recommended trainings by 5/14/2021. |
06/15/2021
| Implemented |
| 6400.52(c)(5) | Staff #1 did not receive annual training the safe and appropriate use of behavior supports. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | Staff #1 will receive the recommended trainings by 5/14/2021. |
06/15/2021
| Implemented |
| 6400.182(c) | Individual #3's annual assessment dated 4/24/2020 states that they are able to safely use and avoid poisonous materials however, these items are locked for safety procedures. Individual #1's ISP states they cannot safely use and avoid poisonous materials. The individual plan shall be revised when an individual's needs change based upon a current assessment. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Program Specialist will ensure that the individual¿s annual assessment and ISP are reviewed and updated on any changes. Request to update the ISP to match the Assessment is attached. Updated ISP is attached. |
06/15/2021
| Implemented |