| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.113(a) | There was only one record of a Fire Safety Training occurring with Individual #1 found within the Individual Record, a training sign-in dated 04/16/2024. As there was no record of a previous Fire Safety Training, it could not be verified that Individual #1 received training in Fire Safety topics annually as required. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | Program Specialist and Program Manager will be re-trained on regulation 113 A. |
09/24/2024
| Implemented |
| 6400.141(c)(11) | Individual #1's most recent Physical Examination, dated 09/20/2023, did not contain an assessment of the individual's medication regimen. The individual's prescribed medications were not noted on or attached to the physical examination form. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | A medication list generated from electronic health record will be presented to doctor at time of annual physical. This medication list will be kept with the annual physical within the electronic health record. |
09/06/2024
| Implemented |
| 6400.141(c)(14) | Individual #1's most recent Physical Examination, dated 09/20/2023, did not note information pertinent to diagnosis and treatment in case of an emergency, if applicable. The area of the physical form designated for this information was left blank by the person(s) completing the form. This information could not be located elsewhere within the physical. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Physical form will be updated to include information missing. |
09/06/2024
| Implemented |
| 6400.142(d) | Individual #1 is edentulous and wears dentures. The medical encounter form associated with Individual #1's most recent Dental Examination, dated 08/08/2024, did not state whether the individual's gums and dentures were checked during the visit. As such, it could not be verified that the individual's gums and dentures were checked during the Dental Examination as required. | The dental examination shall include teeth cleaning or checking gums and dentures. | Program Specialist will request additional documentation from the dentist to outline that his gums and dentures were checked. |
09/06/2024
| Implemented |
| 6400.151(c)(3) | Staff #1's Staff Physical Examination, dated 08/28/2023, did not note whether the staff was free from communicable diseases. The area of the form designated for this information was left blank by the person(s) completing the form and the information was not located elsewhere in the staff record. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | Human Resources was counseled on the importance of verifying staff physical¿s are through and complete. |
08/23/2024
| Implemented |
| 6400.46(b) | Staff #2's Staff Training Record contained documentation of a Fire Safety Training occurring on 07/10/2023; however, there was no documentation of a more recent Fire Safety Training. This staff has not received training in Fire Safety topics annually as required. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Staff will complete fire safety training by 8/30/24 |
08/30/2024
| Implemented |