| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.111(a) | Individual #3, date of admission 11/30/2022, had a physical examinatio0n completed 12/12/2022. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | All program specialist have received training in Chapter 2380.111 (a). Individual # 3 going forward will have physicals done on time and annually thereafter. |
04/27/2023
| Implemented |
| 2380.111(c)(4) | Individual #3's physical examination completed 12/12/2022 did not include a hearing and vision screening. It was left blank. Individual #4's physical examination completed 2/28/2023 documents a vision and hearing screening are recommended and there is no documentation of a follow-up since. | The physical examination shall include: Vision and hearing screening, as recommended by the physician. | All program specialist have received training in Chapter 2380.111 (c)(4). Individuals 3 and 4 will have their physicals updated. Attempts will be made to contact house staff/guardians to have physicals corrected. |
04/27/2023
| Implemented |
| 2380.111(c)(5) | Individual #3, date of admission 11/30/2022, had a Tuberculin skin test read 12/15/2022. | The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted. | All program specialists have received training on Chapter 2380.111(c)(5). all individuals will have TB read in time allotment required by regulations before being admitted into the program. |
04/27/2023
| Implemented |
| 2380.113(c)(2) | Direct Service Worker #1, date of hire 5/02/2022, has not had an initial Tuberculin skin test. | The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant. | All Staff will be required to have a physical and Negative TB result before hire. All physicals will be completed in writing by medical staff allowed to give and read the result. |
04/27/2023
| Implemented |
| 2380.181(a) | Individual #2 had an assessment completed 1/14/2022 and then again 2/03/2023. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. | All program specialist have received training on Chapter 2380.181(a). All individual(s) will have their initial assessments done within 1 year prior to or 60m calendar days after admission to the facility and an updated assessment annually thereafter. |
04/27/2023
| Implemented |
| 2380.182(c) | Individual #1's assessment completed 3/24/2023, Individual #2's assessment completed 2/03/2023, Individual #3's assessment completed 11/30/2023, and Individual #4's assessment completed 3/24/2023 were copied directly from the individuals' individual support plan. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | All program specialist have received training on chapter 2380.182(c). All individuals plans will be developed, revised annually and revised when an individual's needs change based upon a current assessment. |
04/27/2023
| Implemented |