| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.63(a) | On 2/14/24 at 11:21AM, the hot water temperature, in the sink in the kitchen of the home, measured 127.9 degrees Fahrenheit. On 2/14/24 at 11:27AM, the hot water temperature in the sink in the bathroom on the first floor of the home, measured 127.9 degrees Fahrenheit. On 2/14/24 at 11:29AM, the hot water temperature at the sink in the ensuite bathroom of Individual #1's bedroom, measured 127.9 degrees Fahrenheit. | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | The water temperature on the water heater tank was turned down on 2/14/24. The temperature of the water in the sinks and showers was measured again on 2/15 and was 116 degrees. |
02/14/2024
| Implemented |
| 6400.34(a) | Individual #1, was informed and explained individual rights on 3/22/22 and then again on 5/24/23. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Supervisors will be trained on annual requirements for client rights reviews and signatures on 3/7/24. Moving forward, the residential department will have a set annual client rights review across the agency. |
03/07/2024
| Implemented |
| 6400.165(g) | Individual #1 had as psychiatric medication review completed on 3/13/23 and then again 7/13/23. The psychiatric medication review completed 12/15/23, Individual #1 did not include the reason for prescribing the medication, the need to continue the medication, and the necessary dosage. [Repeated violation-2/28/23, et al] | 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. | Site Supervisors were trained on documentation needed for a psychiatric appointment including medications as well as the requirements of a psychiatrist on 2/29/24 |
03/29/2024
| Implemented |