| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.103 | The home evacuation plan does not describe the individuals responsibilities in an emergency. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| The Program Specialist updated the homes emergency evacuation plan to include the responsibilities of the clients in the home. Program Supervisor trained the CCR in the home on the updated plan between 5/19/2022 & 5/24/2022, copy of the staff training log is Attachment # 4. The CCR will train any clients in the home as well as all staff working in the home between 5/19/2022 & 5/26/2022. A copy of the training log is Attachment # 31. |
05/26/2022
| Implemented |
| 6400.112(h) | The home has two designated meeting places, "bush to the left of parking spaces back of house/and directly across st. from front of residence" There should only be one designated meeting place listed in case of a fire. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | The Program Specialist updated the homes emergency evacuation plan to include the responsibilities of the clients in the home. Program Supervisor trained the CCR in the home on the updated plan between 5/19/2022 & 5/24/2022, copy of the staff training log is Attachment # 4. The CCR will train any clients in the home as well as all staff working in the home between 5/19/2022 & 5/26/2022. A copy of the training log is Attachment # 31. |
05/26/2022
| Implemented |
| 6400.15(b) | The Self-Assessment completed 2/28/22 did not indicate that regulations 62a and 62b were measured. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | Director of Quality Assurance re-assessed the self-assessment and completed regulations 6500.62a and 62b on 5/6/2022 as Attachment #32. |
05/18/2022
| Implemented |
| 6400.165(g) | The list of medications listed on the psychiatric medication review form for Individual #1 does not list the reason for each of the medications prescribed for the following dates- 4/27/22, 3/18/22, 2/16/22. | 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. | Program Specialist has developed a new quarterly Psychiatric Mediation Review form that will include each medication along with the reason for prescribing each of the medications and if it should be continued, this form is being used now. |
05/25/2022
| Implemented |