| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.113(a) | Individual #5 was admitted to the home on 7/13/24 and fire safety training was not completed until 9/17/24. | 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. | Upon admission to the home, the Program Specialist will meet and review with the individual the individual rights including the process to report a rights violation. The Program Specialist was trained in the requirements of individual rights information upon admission to the home. Attachment #9 |
04/11/2025
| Implemented |
| 6400.181(a) | Individual #5 was admitted to the home on 7/13/24 and there was no assessment on file for the individual. | 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. | Upon admission to the home, the Program Specialist will complete an individual assessment within 60 calendar days. The assessment was completed on 9/12/24 but was not present in the file. The Program Specialist was trained in the requirements of individuals upon admission to the home.
Attachment #9 &10 |
04/11/2025
| Implemented |
| 6400.34(a) | Individual #5 was admitted to the home on 07/13/2024 and the individual rights information was not signed until 9/17/2024. | 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. | Upon admission to the home, the Program Specialist will meet and review with the individual the individual rights including the process to report a rights violation. The Program Specialist was trained in the requirements of individual rights information upon admission to the home. Attachment #9 |
04/11/2025
| Implemented |