| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | The dish soap present on kitchen counter during the inspection was not locked with other poisons. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Provider's Plan of Correction:
May 23, 2025- The administrator removed the dish soap from the sink and placed it with the locked poisonous materials.
May 27, 2025- A the administrator and chief operating officer held staff meeting. All DSP and supervising staff were educated on the importance of locking all poisonous materials after usage. |
05/23/2025
| Implemented |
| 6400.77(b) | The first aid kit does not have a thermometer. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | May 23, 2025 -- The chief operating officer purchased a thermometer and provided it prior to the completion of the inspection.
May 27, 2025- The administrator and chief operating officer held a staff meeting and educated DSP, Front line supervising and nursing staff on the importance of ensuring all required items are within the first aid kit. |
05/23/2025
| Implemented |
| 6400.141(c)(4) | A vision and hearing screening was not included in the annual physical examination for individual 1. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | On May 27, 2025, the administrator and COO held a staff meeting to remind DSP, frontline supervisors, and nursing staff to ensure all medical provider documents are completed in their entirety at appointments.
May 27, 2025- DSP staff made a follow up appointment with individual 1s primary care doctor to have the physical form corrected.
July 16, 2025- The front-line supervisor accompanied individual 1 to a follow up medical appointment. The nurse at the doctor's office verified that the vision and hearing screening were completed at a previous physical appointment and updated the form and provided a signature. |
07/16/2025
| Implemented |
| 6400.142(e) | A 06/11/24 dental exam for individual 1 ordered a follow up visit in 3 to 6 months and there was no follow up appointment attended. | Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed. | On May 27, 2025, the administrator and chief operating officer conducted a staff meeting to emphasize to DSPs, front-line supervisors, and nursing personnel the importance of scheduling and attending all appointments at the recommended times.
May 27, 2025- Administrator contacted special smiles dental office to schedule a new patient appointment for individual 1. As individuals, 1 previous appointment was located inside a child RTF and a follow up appointment could not happen at that facility. The dentist's office requests an intake package and a medical appointment from primary care before scheduling an appointment. The CLA submitted all required documentation.
July 16, 2025 -- Individual 1 attended a primary care appointment to obtain medical clearance needed for a dental appointment under general anesthesia. The necessary documents were sent to the dental office.
TBD- Administrator is waiting for staff at the dental office to verify all medical documents are cleared to schedule individual 1 for an Intake appointment to prepare for dental treatment under general anesthesia. |
09/30/2025
| Implemented |
| 6400.142(f) | There was no written plan for dental hygiene for individual 1. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | On May 27, 2025, the administrator and chief operating officer conducted a staff meeting to emphasize to DSPs, front-line supervisors, and nursing personnel the importance of scheduling and attending all appointments at the recommended times.
May 27, 2025- Administrator contacted special smiles dental office to schedule a new patient appointment for individual 1. As individuals, 1 previous dental appointment was located inside a child RTF and a follow up appointment could not happen at that facility. The dentist's office requests an intake package and a medical appointment from primary care before scheduling an appointment. The CLA submitted all required documentation.
July 16, 2025 -- Individual 1 attended a primary care appointment to obtain medical clearance needed for a dental appointment under general anesthesia. The necessary documents were sent to the dental office.
TBD- Administrator is waiting for staff at the dental office to verify all medical documents are cleared to schedule individual 1 for an Intake appointment to prepare for dental treatment under general anesthesia. |
09/30/2025
| Implemented |