| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.144 | Several of Individual #1's PRN medications were not in the home during inspection but were listed on the MAR (Eucerin Cream, Geri-Tussen, Diabetic Tussen, SPF50 Sunblock, Off! Insect repellant, Loratadine tablets, Deep Sea nasal spray) . Medications also included a sealed bottle of Beano tablets with an inaccurate pharmacy label for Lactaid tablets. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Immediately after inspection the agency CEO contacted the individual's PCP to request updated prescriptions be sent to the pharmacy for drop off of all PRNs. As of 8/10/26 all medications have been filled. To prevent future occurrences of this nature, upon initial transition the agency CEO will request not only a 60 day prescription for all standard medications, but also that all noted PRNs be transitioned with the individual as well. Post transition all PRNs will be obtained through the pharmacy on a situational basis, and will be refilled. The agency's Client Acceptance Letter Template (Attachment 1) has been updated to include a requirement for the individuals to be transitioned with all medications, including PRNs. The Master Roles Checklist (Attachment 2) also requires the agency CEO to ensure retention of all medications, including PRNs during a transition. The House Manager, who is also currently the agency Managing Director, has a role updated in the Master Roles Checklist, that requires the auditing of all medications for refills, including PRNs. In the event that a new House Manager is hired, they will be acclimated/trained on the elements of the Master Roles Checklist, specially medication related duties. Upon document modification, the current House Manager/Managing Director was made aware of the changes. |
08/10/2026
| Implemented |
| 6400.151(a) | The initial physical for Staff Person #2 was completed 7/15/2025. The hire date was 7/9/2025. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | All other staff files were audited to ensure that hire dates were after Physical Examinations. Because this specific situation cannot be retroactively remedied, the agency will ensure that all staff hire dates follow the date of the examination. The agency CEO facilitates all staff onboarding, and will continue to utilize the Master Roles Checklist (Attachment 2), which specifies a need to review all staff onboarding files on a monthly basis. The Direct Support Staff Onboarding Checklist specifies that all Physical Examinations must be completed in advance of hire. |
08/10/2026
| Implemented |
| 6400.151(c)(3) | Physical completed on 1/3/2025 does not indicate whether or not Staff Person #1 is free from communicable diseases as the physician failed to check off box as yes or no. | 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. | The agency CEO, who is also the staff member being referenced, sent the PCP a form on 8/21/26 to be completed reflective of 2026 physical information and will ensure thorough completion of the document. At this time there are no other physical forms within the agency that do not meet this measure. At this time it is unknown when the document will be returned, so a 10/1/26 completion date has been established. |
10/01/2026
| Implemented |
| 6400.181(a) | The annual assessments for Individual #2 dated 01/28/2026 and 02/14/2025 are functionally identical in content and do not describe individual progress or changes over the previous year. | 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. | The agency CEO/Program Specialist will revisit and updated the individual's 2026 Functional Assessment and be sure to input any necessary information by way of observation, interviews, historical documentation, and other pertinent data by 10/1/26. The Regulatory Compliance Guide, specifically measure 181 will be referenced for thoroughness. No other individual has this need, due to the other individual in the agency having transitioned in 2026 and his Functional Assessment being new and the sole document of its type. |
10/01/2026
| Implemented |
| 6400.18(a)(13) | Incident 9861206 regarding Individual #1 occurred on 6/3/2026. The incident was entered into EIM on 6/7/2026. The nature of the incident required entry within 24 hours of discovery as the incident was categorized as a rights violation. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
A violation of individual rights. | The agency CEO and Managing Director facilitated a Staff Meeting on 8/9/26 to re-emphasize the newly updated clause in the agency Incident Management Policy (Attachment 5), which discusses the necessity for timely reporting of all incidents, and the capacity for disciplinary action, up to and potentially including employee termination, for failure to report any incident on time. There are no outstanding incidents that this measure is applicable to, and all past incidents have been evaluated for a need for corrective actions, all of which have been implemented. All staff have been instructed to sign a Staff Memo following the meeting on 8/9/26. All signatures should be obtained by 9/1/26. |
09/01/2026
| Implemented |
| 6400.24 | The Controlled Substances Act of 1970 requires accurate counts of controlled medication be kept. Individual #1's Nayzilam 5mg nasal spray and Diazepam 5mg tablets did not have count sheets kept. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | The CEO will implement the use of a Controlled Substance Sheet (Attachment 6) on 9/1/26 alongside the individual's September MAR. There are no other Controlled Substances being administered to the other individual the agency serves. |
09/01/2026
| Implemented |
| 6400.166(a)(11) | Individual#1's MAR did not list the diagnosis or reason for some of their prescription medicines.
Individual #2' MAR did not list the diagnosis or reason for each prescription medicine. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Both agency's individuals had MARs that will be reviewed by the agency CEO and updated for all medications that do not note diagnoses, and the diagnoses will be input where missing by 10/1/26. These are the only two individuals in the agency, so the only two needed to be audited. In the future, upon intake it is the duty of the agency Nurse to produce the MAR and input diagnoses for all medications. The agency's Master Roles Checklist (Attachment 2) now lists the task of Medication Administration Record to include diagnoses for all medications as a part of the Nurse's Client Onboarding Tasks, and the Client Onboarding Checklist (Attachment 7) also lists the need for the MAR to be completed, with a note about including diagnoses when completing. For medication changes and MAR add ons post transition, the Nurse's roles have been expanded to include 'Medication Changes w/ Physician Verification' with the detail of implementing MAR changes to include diagnoses. |
10/01/2026
| Implemented |
| 6400.166(a)(13) | Individual #2's medications due at 8 am on the date of inspection were not initialed to indicate administration, and the inspector could not determine if those medications were distributed that morning based on the available information. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | In the event that medication is to be administered to an individual while external to the home, staff will input on the comments section of the MAR that an outing has/or is occurring, with the date and time.
Upon returning the staff member will formally sign out the medications that were administered with their initials in the required time slot and date of administration. |
10/01/2026
| Implemented |