| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 20.34 | 1)- The closet located in room #5 could not be accessed.
2) -The door (labeled Sprinkler Room) could not be accessed during the physical site inspection. | The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients. | The lock was replaced on the closet in room #5, and key obtained for the Sprinkler room door, attachment. |
| Implemented |
| 6400.22(e)(1) | The agency is responsible for Individual 21's finance, it was discovered that the amounts are not being documented clearly on the money report and actual receipts that exceed $15.00 are being provided. The agency did not provide a record of financial resources that include the dates and amounts of deposits and withdraws. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. | If Woods is the representative payee for an individual, prior to issuing any money to an individuals¿ family the Residential Manager will:
1. Discuss the planned expenses for the requested funds to ensure they are allowable under social security rules
2. Determine the amount needed to cover the planned expenses
3. Explain that receipts must be supplied within 30 days of the money being issued
4. Explain that receipts must also include an itemized list of what exactly was purchased since many receipts are not that explicit.
5. Should the family fail to adhere to the above guidelines than further requests for cash will not be issued |
05/30/2024
| Implemented |
| 6400.72(a) | There were no screens in the windows in rooms #1, #2, #7, #8, and room #13 (the laundry room) | Windows, including windows in doors, shall be securely screened when windows or doors are open. | New window screens installed in bedroom windows, attachment. |
02/16/2024
| Implemented |
| 6400.72(b) | Individual Rooms #1 and#8 window is damaged and need repaired (won't remain open). | Screens, windows and doors shall be in good repair. | New window screens installed, attachment. |
05/15/2024
| Implemented |
| 6400.81(k)(6) | Individuals Rooms #2, #8, #11 had no mirrors. | In bedrooms, each individual shall have the following: A mirror. | New mirrors installed, attachment. |
01/28/2024
| Implemented |
| 6400.141(c)(3) | The physical examination form dated 01/21/23 did not include Immunizations for individual #21. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Michael had a physical exam on 1/24/24. The physician reviewed Michael's immunization history and determined that his immunizations per the CDC recommendations are appropriate, attachment. |
01/24/2024
| Implemented |
| 6400.181(a) | An annual updated assessment was not completed for individual #21, last assessment was completed 12/13/21 and not completed again until 01/09/23. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Assessment timelines, expectations and the importance of meeting regulatory requirements will be reviewed with the assigned Case Manager by the Assistant Director of Case Management on 5/13/24, attachment. |
05/13/2024
| Implemented |