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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.111(c)(5) | Individual #1, date of admission 4/30/2024, did not have a Tuberculin skin test with negative results as part of a physical examination within 12-months prior to admission. | 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. | Physical checklist has been implemented to ensure compliance on all areas of physicals on 4/21. |
04/21/2025
| Implemented |
| 2380.111(c)(10) | Individual #3 most recent physical examination, completed on 10/7/24, did not address medical information pertinent to diagnosis and treatment in case of an emergency. In the section relative to this regulation, the term, "yes" was circled. However, its corresponding information field was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Required information has been corrected on physical on 4/21. Physical checklist has been implemented to ensure compliance on all areas of physicals on 4/21. |
04/21/2025
| Implemented |
| 2380.111(c)(11) | Individual #3 most recent physical examination, completed on 10/7/24, did not address special instructions regarding diet. In the section entitled, "Weight Control/ Dietary," the term, "yes" was circled. However, its corresponding field that read, "If yes, please describe," was left blank. | The physical examination shall include: Special instructions for an individual's diet. | Required information has been corrected on physcial on 4/21. Physical checklist has been implemented for the Program Specialists to maintain to ensure compliance on all areas of physicals on 4/21. |
04/21/2025
| Implemented |
| 2380.182(c) | Individual #3 Individual Support Plan, last updated on 8/9/24, was not revised to reflect their current needs as based on their current assessment, completed on 5/7/24, and differed in the following health and safety skill domains: regarding non-insulated heat sources exceeding 120 degrees Fahrenheit, Individual #3 Individual Support Plan reported that they are independently aware of such heat sources, while their assessment indicated that Individual #3 requires verbal assistance to sense and quickly move away from dangerous heat sources; and regarding supervision needs, Individual #3 Individual Support Plan informed that within the facility, they require a 1:7 staffing ratio with auditory supervision always being maintained and that they may be left alone in the bathroom or a quiet/ private area for up to ten minutes. However, for training purposes, Individual #3 must have a 1:1 staffing ratio. In the community, Individual #3 must receive total supervision at all times in the form of a 1:4 or greater staffing ratio. In contrast, Individual #3 assessment indicated that they require physical-to-total assistance supervision at all times in the facility and while in the community, Individual #3 needs supervision at all times, including verbal prompting in using the public restroom and hand-over-hand support in crossing streets. The agency provided documentation in the form of an email sent on 3/28/25 to Individual #3 Supports Coordinator requesting an update to facility and community supervision regarding staffing ratios. However, supervision staffing ratios were not indicated in Individual #3 assessment. Individual #2 Individual Support Plan, last updated on 7/26/24, was not revised to reflect their current needs as based on their current assessment, completed on 12/30/24, and differed in the following health and safety skill domains: regarding non-insulated heat sources exceeding 120 degrees Fahrenheit, Individual #2 Individual Support Plan reported that they are able to independently sense and quickly move away from such heat sources, while their assessment indicated that Individual #2 requires verbal assistance to do so; and regarding fire safety evacuation, Individual #2 Individual Support Plan explained that Individual #2 looks to staff for assistance in the event of an evacuation, while their assessment indicated that they can safely evacuate with independence in the event of a fire. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | An email was sent to the Support Coordinator for invidual #2 requesting that the ISP be updated to reflect requested changes on 5/19. Addendum's to the functional assessment for both individual #2 and #3 were added by the Program Specialist to ensure that the assessment and the ISP are consistant in regard to these areas. |
04/23/2025
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.53(a) | At 1:13PM, four 4 ounce containers of Hibiclens Chlorhexidine Gluconate Solution 4.0% Antiseptic/Antimicrobial Skin Cleanser with instructions to contact Poison Control if ingested was unlocked and accessible in a drawer in the men's bathroom. At 1:19PM, a container of Member's Mark Dishwasher All in One Pacs was unlocked and accessible in the cabinet under the sink in the kitchen. [Repeat Violation, 5/11/2023] | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | The bathroom cleaner was discarded on 4/17/24 and a lock was installed under the kitchen cabinet by maintenance for an additional storage area for poisons. |
04/29/2024
| Implemented |
| 2380.181(f) | Program Specialist #1 provided Individual #1's annual assessment, completed 2/15/2024, to the plan team members on 3/12/2024 for the Individual Plan meeting on 4/10/2024. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting. | All assessments will be reviewed by the Program Supervisor by 5/3/24 and documented on a shared program spreadsheet to determine next assessment dates and previous ISP meeting dates. |
05/03/2024
| Implemented |
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