| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | At the time of the inspection, located at the kitchen sink was a Softsoap Antibacterial Handsoap Kitchen fresh hands scent and it was filled approximately ¾ of the way with a blue liquid. Also, located on the sink was a bottle of Dawn Platinum Fresh Rain Dish Soap that contained less than approximately ¼ of the way with a blue liquid. When the Licensing Representative asked the agency staff if they fill the Softsoap container with the Dawn liquid they declined that action, and that the Softsoap Antibacterial Handsoap Kitchen fresh hands scent is a blue liquid. However, a google search of that specific product, Softsoap Antibacterial Handsoap Kitchen fresh hands scent, shows that the liquid is a yellow/orange color | Poisonous materials shall be stored in their original, labeled containers. | Soap was removed and replaced on 7/10/25. Staff were retained on poisonous chemicals on 7/12/2025. |
07/12/2025
| Implemented |
| 6400.112(e) | A sleeping drill was conducted on 6/30/24 at 2:30 am, and the next one did not occur until 2/21/25 at 2:30 AM. | A fire drill shall be held during sleeping hours at least every 6 months. | A fire drill calendar was created by manager to ensure fire drills were conducted in accordance with ODP regulations. 7/12/25
((Calendar can only be shared with staff member responsible for setting off the alarms and conducting the fire drill -CH 8/19/25)) |
07/12/2025
| Implemented |
| 6400.112(g) | The fire drill conducted on 6/30/24 and 2/21/25 both occurred at 2:30 am. | Fire drills shall be held on different days of the week and at different times of the day and night. | Manager will ensure all drills conducted were done on a different time. |
07/12/2025
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination dated 3/10/25 did not include medical information pertinent to diagnosis and treatment in case of an emergency this section of the exam was left blank on the form. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Program staff by were trained Agency nurse on how to properly fill physical form and other medical appointments forms. Training occurred 7.20.25 |
07/20/2025
| Implemented |
| 6400.15(b) | The agency will use the department licensing inspection instrument for the community homes to measure compliance. The self-inspection tool provided at the time of inspection was completed on an incorrect form. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | Agency Director will ensure correct form is filled and submit to CEO to ensure proper form is fill |
07/20/2025
| Implemented |
| 6400.46(d) | Staff #2 was trained/certified in cardio-pulmonary resuscitation (CPR) and first aid on 8/4/22 and it expired in 2 years (8/4/24). Staff #2 next CPR training/certification was completed on 6/19/25. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | HR Manager will audit all file on a bi-monthly basis to ensure compliance. Starting from 7.12.25 all staff files were audited to ensure compliance. |
07/12/2025
| Implemented |
| 6400.52(a)(1) | Staff #2 only completed 22 hours of training. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | HR will keep a calendar of all staff training due dates to ensure compliance. If a training is coming due, HR will schedule training for staff and ensure 24 hours training compliance is meet. |
07/12/2025
| Implemented |
| 6400.163(h) | Individual #1 is prescribed SF 5000 Plus CRE 1.1%, use a pea size amount twice a day as needed for dental cariel. The pharmacy label had a use by date of 05/17/2025. This medication remains with Individual #1's medication in the home and has not been disposed of properly. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Medication was removed immediately at the time of inspection . Manager will conducted weekly medication check to ensure compliance |
07/10/2025
| Implemented |
| 6400.166(a)(4) | According to the Regulatory Compliance Guide (RCG) Over the Counter (OTC) medication medications must be recorded on the Medication Administration Record (MAR). Individual #1 is prescribed CVS Saline 0.65% Nasal spray, spray 1 spray into each nostril as needed for congestion or rhinitis and the medication was not listed on Individual #1's July 2025 MAR. The MAR did not include the name of the medication, strength of the medication, dosage form, dose of the medication, route of administration, frequency of administration, diagnosis, or purpose for the medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | Medication was recorded immediatey upon discovery of the error. Manager will conduct weekly medication checks to ensure compliance |
07/10/2025
| Implemented |
| 6400.166(b) | Individual #1's is prescribed Lansoprazole 30mg, take 1 capsule by mouth twice a day at 9am and 9pm for acid reflux. Individual #1's July Medication Administration Record (MAR) did not include the initials of the staff that the medication was administered at 9pm from 7/1/25-7/9/25. The medication appeared to be administered from the blister card on those days. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Staff were retrained on 7.12.25 on medication documentation. Moving Forward, Program manager will conduct daily checks to ensure compliance. |
07/12/2025
| Implemented |
| 6400.169(a) | A staff person who has successfully completed a Department-approved medication administration course, including the course renewal requirements, may administer medications, injections, procedures, and treatments. The departments medication administration training program annual practicum requirements are two Mediation Administration Record (MAR)Reviews Completed within expected time frame in 1 year period (1 observation every 6 months), and Two Medication Observations Completed within expected time frame in 1 year period (1 observation every 6 months).Staff #1's annual medication administration practicum dated 4/18/25 had MAR reviews completed on 4/17/25 and 4/18/25, and the 2 observations done on 4/17/25 and 2 observations were done on 4/18/25. Staff #2's annual medication administration practicum dated 4/17/25 MAR reviews completed on 4/17/25 and 4/18/25, and the 2 observations done on 4/17/25 and 2 observations were done on 4/18/25. Staff medication administration training is not being conducted as prescribed by the medication administration training course. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | Staff were retrained by agency medication trainer on medication administration on 7.24.25 |
07/24/2025
| Implemented |