| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(h) | The fire drills completed on 10/30/24 and 11/19/24 do not indicate if all participants arrived safely to the designated meeting place or not. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | A fire drill will be completed no later than 5/31/2025 with the Director of Quality Assurance to ensure everyone in the home is able to arrival safely at the meeting place. A completed Fire Drill form for May 2025 will be sent as Attachment #34. The Residential Program Specialist and Residential Coordinator will be trained on Regulation 6400.112(h) no later than 5/31/2025 by the Director of Quality Assurance and will be sent as Attachment #35. |
05/31/2025
| Implemented |
| 6400.141(c)(4) | Individual #1 had a vision exam on 3/6/24 and not again until 4/8/25. Both the 2024 and 2025 physical recommended annual vision exams. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | The Residential Program Specialist and Residential Coordinator will be trained on Regulation 6400.141(c)(4) by the Director of Quality Assurance no later than 5/31/2025 and will be sent as Attachment #37. |
05/31/2025
| Implemented |
| 6400.181(e)(9) | The 6/30/24 annual assessment for individual #1 only provides a list of diagnoses in this section and does not fully explain the functional and medical limits related to the individual's disability or these diagnoses. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | The Residential Program specialist only listed the diagnosis instead of addressing any medical or functional limitations. The Residential Program Specialist wrote an addendum to the Assessment for Individual #1 to include the medical and functional limitations on 4/28/2025, see Attachment #40. |
05/31/2025
| Implemented |
| 6400.181(e)(11) | The 6/30/24 annual assessment does not include information regarding a psychological and if it is applicable or not. | The assessment must include the following information: Psychological evaluations, if applicable. | The Residential Program Specialist wrote an addendum to the Assessment for Individual #1 to include information related to the psychological evaluation on 4/28/2025, see Attachment #40. |
05/31/2025
| Implemented |
| 6400.213(1)(i) | 213 (1)(vi) The photograph in the record for individual #1 is not current as it was last updated 7/3/23. | 213 (1)(vi) Each individual's record must include the following information: A current, dated photograph. | A current picture of individual #1 was taken on 4/29/2025 and placed in the file, see Attachment #43. |
05/31/2025
| Implemented |