| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.63(a) | On 2/13/2025 at 10:43AM, the hot water temperature measured 123.2°F at the sink in the kitchen of the home. | 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 Maintenance Team adjusted the water heater settings to ensure that hot water remains within the required temperature range across all faucets. |
02/14/2025
| Implemented |
| 6400.67(a) | On 2/13/2025 at 10:53AM, the banister above the staircase on the second floor of the home was not sturdy and wobbled when in use. | Floors, walls, ceilings and other surfaces shall be in good repair. | To correct this issue, the Maintenance Team was assigned to reinforce and secure the banister, ensuring it is stable and safe for use. The repair was completed by March 4, 2025, and the banister was inspected to confirm compliance with safety standards. |
03/04/2025
| Implemented |
| 6400.68(b) | On 2/13/2025 at 10:57AM, the hot water temperature measured 123.6°F at 10:57AM at the bathtub in the bathroom on the second floor of the home. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The Maintenance Team adjusted the water heater settings to ensure that hot water remains within the required temperature range across all faucets. |
02/14/2025
| Implemented |
| 6400.101 | On 2/13/2025 at 10:54AM, there were two hook and eye locks on the inside of the door of the vacant bedroom on the second floor of the home. At 10:56AM, there were two chain link locks on the door in the staff office on the second floor of the home. At 11:01AM, there were hook and eye locks on the inside of both of the doors in the bathroom on the second floor of the home. [Repeat Violation, 2/13/2024] | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| To immediately correct the issue, the CEO removed the hook and eye locks and chain link locks from all doors on the day of inspection to prevent potential obstruction. Additionally, the Maintenance Team, under the oversight of the Program Director, replaced all locks with one that is compliant. |
02/14/2025
| Not Implemented |
| 6400.112(a) | An unannouced fire drill has not been conducted at the home since Individual #1's admission on 10/9/2024. | An unannounced fire drill shall be held at least once a month. | To correct this issue, the Program Director and Director of Operations have implemented a fire drill tracking system with a clear timeline for all required fire drills. Staff members are now required to complete fire drills as scheduled and immediately upload the completed documentation to the company¿s designated platform for secure record-keeping. Additionally, the Program Director will conduct monthly audits to verify that all fire drill reports are properly documented and stored. |
02/24/2025
| Not Implemented |
| 6400.151(a) | Direct Service Worker #2, who began working with Individuals on 10/12/2024, has not completed a physical examination. | 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. | To correct this issue, the agency has developed a compliance tracker to monitor and verify that all staff members have the necessary documentation before providing direct care. The HR Director and Director of Operations are now responsible for verifying the dates of required documents, ensuring compliance before any staff member can engage with an individual. This tracking system was implemented immediately and will be maintained as an ongoing compliance measure. |
02/17/2025
| Implemented |
| 6400.32(r)(1) | On 2/13/2025, there was a pinhole lock on the door leading to Individual #1's bedroom. Individual #1 has not been provided with a designated mechanism to lock and unlock the door independently. | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | To immediately correct the issue, the Maintenance Team, under the oversight of the Program Director, removed the pinhole lock and replaced it with a compliant lock. A key was also provided for the individual and the staff member on shift to ensure proper access. This corrective action was started February 27, 2025 and completed on March 4, 2025. |
03/04/2025
| Not Implemented |
| 6400.32(r)(5) | On 2/13/2025, there was a pinhole lock on the door leading to Individual #1's bedroom. Staff did not have a designated mechanism to lock and unlock the door. | Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door. | To immediately correct the issue, the Maintenance Team, under the oversight of the Program Director, removed the pinhole lock and replaced it with a compliant lock. A key was also provided for the individual and the staff member on shift to ensure proper access. This corrective action was started February 27, 2025 and completed on March 4, 2025. |
03/04/2025
| Not Implemented |
| 6400.34(a) | Individual #1 was informed and explained individual rights on 10/6/2024. The rights document did not include the following rights: 6400.32p, an individual has the right to choose persons with whom to share a bedroom; 6400.32q, an individual has the right to furnish and decorate the individual's bedroom and the common areas of the home in accordance with § 6400.33 (relating to negotiation of choices); 6400.32(s), an individual has the right to have a key, access card, keypad code, or other entry mechanism to lock and unlock an entrance door of the home.- | 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. | To correct this issue, the Chief Executive Officer and Program Director reviewed and revised the Individual Rights Form to ensure it accurately reflects all rights in accordance with 6400.34(a). The updated form was implemented immediately and will now be provided to all individuals upon admission and during their annual rights review. Individuals currently receiving services will also be given the updated form to review and sign by March 14, 2025. |
03/14/2025
| Not Implemented |
| 6400.46(a) | Direct Service Worker #2, who began working with individuals on 10/9/2024, completed an online training in general fire safety on 10/8/2024. This training did not include home specific information. | Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | To correct this issue, the CEO and Program Director have updated the training attendance documentation to explicitly include home-specific fire safety information for each residence. All staff documentation has been updated to reflect the fire safety training with detailed, site-specific protocols recorded on their attendance forms. This updated documentation process was implemented immediately. |
02/17/2025
| Not Implemented |
| 6400.46(b) | Chief Executive Officer #1, who began working with Individuals on 10/9/2024, most recently completed fire safety training on 1/9/2024. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | To correct this issue, the CEO and Program Director have reviewed and updated fire safety training records to accurately reflect the most recent training conducted in 2024 and 2025. Moving forward, all fire safety training sessions will be documented immediately upon completion, with clear timestamps and details of the training content. This corrective action was completed immediately upon identification of the issue. |
02/14/2025
| Not Implemented |
| 6400.46(c) | Direct Service Worker #2, who began working with individuals on 10/12/2024, did not complete training in basic first aid. | Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home shall be trained before working with individuals in first aid techniques. | To correct this issue, the agency has developed a compliance tracker to monitor and verify that all staff members have the necessary documentation before providing direct care. The HR Director and Director of Operations are now responsible for verifying the dates of required documents, ensuring compliance before any staff member can engage with an individual. This tracking system was implemented immediately and will be maintained as an ongoing compliance measure. |
02/17/2025
| Implemented |
| 6400.51(b)(1) | Direct Service Worker #2 began working with individuals on 10/12/2024 and the orientation did not include job related knowledge and skills. | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | To correct this issue, WellCared Services has incorporated a compliance tracker to ensure all staff members have documented proof of their training, including job-related knowledge and skills. The HR Director and Director of Operations will verify and approve all training records before allowing staff to engage with individuals. Additionally, training documentation has been updated to explicitly outline the job-related knowledge and skills covered to prevent any ambiguity in compliance records. |
02/19/2025
| Not Implemented |
| 6400.166(a)(4) | Individual #1's January 2025 Medication Administration Record did not include the name of Dakin's Solution. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | To correct this issue, WellCared Services has developed a hospital discharge return procedure that requires staff to immediately check all items sent home with the individual, including medications. As part of this procedure, staff must notify the Medication Trainer whenever a medication is present in the individual¿s belongings to ensure proper documentation in the Medication Administration Record (MAR). |
03/12/2025
| Not Implemented |
| 6400.166(a)(5) | Individual #1's January 2025 Medication Administration Record did not include the strength of Dakin's Solution. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | To correct this issue, WellCared Services has developed a hospital discharge return procedure that requires staff to immediately check all items sent home with the individual, including medications. As part of this procedure, staff must notify the Medication Trainer whenever a medication is present in the individual¿s belongings to ensure proper documentation in the Medication Administration Record (MAR). |
03/12/2025
| Not Implemented |
| 6400.166(a)(6) | Individual #1's January 2025 Medication Administration Record did not include the dosage form of Dakin's Solution. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | To correct this issue, WellCared Services has developed a hospital discharge return procedure that requires staff to immediately check all items sent home with the individual, including medications. As part of this procedure, staff must notify the Medication Trainer whenever a medication is present in the individual¿s belongings to ensure proper documentation in the Medication Administration Record (MAR). |
03/12/2025
| Not Implemented |
| 6400.166(a)(7) | Individual #1's January 2025 Medication Administration Record did not include the dose of Dakin's Solution. Individual #1 is prescribed Polyethylene Glycol 3350 with instructions to, "Dissolve 17 grams in 8 ounces of water and drink by mouth daily as needed for constipation." Individual #1's January 2025 Medication Administration Records reads, "give one scoop by mouth as needed daily for constipation." | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | To correct this issue, WellCared Services has developed a hospital discharge return procedure that requires staff to immediately check all items sent home with the individual, including medications. As part of this procedure, staff must notify the Medication Trainer whenever a medication is present in the individual¿s belongings to ensure proper documentation in the Medication Administration Record (MAR). Additionally, the Med Trainer will conduct monthly audits to ensure medication directions on the MAR match the orders from the doctor as well as what appears on the medication label. |
03/12/2025
| Not Implemented |
| 6400.166(a)(8) | Individual #1's January 2025 Medication Administration Record did not include the route of administration of Dakin's Solution. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | To correct this issue, WellCared Services has developed a hospital discharge return procedure that requires staff to immediately check all items sent home with the individual, including medications. As part of this procedure, staff must notify the Medication Trainer whenever a medication is present in the individual¿s belongings to ensure proper documentation in the Medication Administration Record (MAR). |
03/12/2025
| Not Implemented |
| 6400.166(a)(9) | Individual #1's January 2025 Medication Administration Record did not include the frequency of administration of Dakin's Solution. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | To correct this issue, WellCared Services has developed a hospital discharge return procedure that requires staff to immediately check all items sent home with the individual, including medications. As part of this procedure, staff must notify the Medication Trainer whenever a medication is present in the individual¿s belongings to ensure proper documentation in the Medication Administration Record (MAR). |
03/12/2025
| Not Implemented |
| 6400.166(a)(10) | Individual #1's January 2025 Medication Administration Record did not include the administration times of Dakin's Solution. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | To correct this issue, WellCared Services has developed a hospital discharge return procedure that requires staff to immediately check all items sent home with the individual, including medications. As part of this procedure, staff must notify the Medication Trainer whenever a medication is present in the individual¿s belongings to ensure proper documentation in the Medication Administration Record (MAR). |
03/12/2025
| Not Implemented |
| 6400.166(a)(11) | Individual #1's January 2025 Medication Administration Record did not include the diagnosis or purpose for Dakin's Solution. | 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. | To correct this issue, WellCared Services has developed a hospital discharge return procedure that requires staff to immediately check all items sent home with the individual, including medications. As part of this procedure, staff must notify the Medication Trainer whenever a medication is present in the individual¿s belongings to ensure proper documentation in the Medication Administration Record (MAR). |
03/12/2025
| Not Implemented |
| 6400.166(a)(13) | Direct Service Worker #2 administered Individual #1's prescribed medications from 1/15/2025 through 1/19/2025. Direct Service Worker #2's name was not on Individual #1's January 2025 Medication Administration Record. | 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. | To correct this issue, a medication retraining session was conducted on February 19, 2025, reinforcing the importance of accurately completing the MAR, including initialing and signing with the full name after each medication administration. All DSPs were required to participate in this retraining to ensure compliance moving forward. |
02/19/2025
| Implemented |
| 6400.167(a)(1) | Indivdiual #1 was discharged from an inpatient stay in the hospital on 1/15/2025 with a prescribed bottle of Dakins Topical Solution Full Strength with instructions to "Give 1 application topically daily." The provider did not administer this medication from 1/15/2025 through 1/19/2025. | Medication errors include the following: Failure to administer a medication. | To correct this issue, WellCared Services has developed a hospital discharge return procedure that requires staff to immediately check all items sent home with the individual, including medications. As part of this procedure, staff must notify the Medication Trainer whenever a medication is present in the individual¿s belongings to ensure proper documentation in the Medication Administration Record (MAR). Additionally, an incident was entered in the EIM and APS was contacted for neglect failure to provide medication management. |
03/12/2025
| Not Implemented |
| 6400.167(a)(4) | Individual #1 is prescribed Hydroxyzine Pam 50MG Cap with instructions to, "take 1 capsule by mouth 3 times day in the morning, at 3:00PM and at bedtime. This medication was administered at 12:00PM from 1/16/2025 through 1/19/2025. | Medication errors include the following: Failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time. | To correct this issue, WellCared Services has hired a Medication Trainer who will be responsible for verifying that the MAR, pharmacy records, doctor¿s orders, and medication labels are fully aligned before medication administration. If any discrepancies are identified, the Medication Trainer will immediately contact the pharmacy to ensure corrections are made to both the MAR and medication labels. Additionally, the updated information will be entered into the electronic Medication Administration Record (eMAR) system to maintain accuracy. |
02/19/2025
| Not Implemented |
| 6400.169(a) | Chief Executive Officer #1 completed the Train the Trainer medication administration training on 11/13/2024. The four medication administration observations required to administer medications were not completed. Chief Executive Officer #1 administered Individual #1's prescribed medications from 1/16/2025 through 1/19/2025. Direct Service Worker #2 completed medication administration training on 1/3/2025. Verification of this training and the four required observations was not provided. Direct Service Worker #2 administered Individual #1's prescribed medications from 1/15/2025 through 1/19/2025. | 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). | To correct this issue, the agency has printed out documentation of course completion certificates available for all staff who have successfully completed the training at WellCared. These certificates are only issued once all course requirements, including the mandatory observation component, have been successfully fulfilled. Staff members who have not yet completed this requirement are not permitted to administer medications until they do so. |
02/14/2025
| Not Implemented |