| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.71 | Emergency telephone numbers were not posted on or near the telephone located in the kitchen. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| The agency site manger shall ensure the emergency telephone numbers are posted on phone located in the kitchen and in other locations of within the home. |
05/22/2025
| Implemented |
| 6400.77(b) | The first aid kit did not include 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. | The site manager and program specialist shall ensure first aid kits at all locations contains the required items including the thermometer. |
05/22/2025
| Implemented |
| 6400.112(c) | The fire drill record for the drill conducted on 11/24/2024 did not document the exit route used. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | The site manager will review fire drill after each drill to ensure proper protocols are followed and ensure documentation are accurate. Staff was trained on proper documentation of fire drill record. |
05/25/2025
| Implemented |
| 6400.112(h) | The fire drill records for the drills conducted on 11/24/2024, 12/24/2024, 1/27/2025 and 2/26/2025 did not document that the individuals evacuated to a designated meeting place. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | The site manager will review fire drill after each drill to ensure proper protocols are followed and ensure documentation are accurate. Staff was trained on proper documentation of fire drill record. |
05/25/2025
| Implemented |
| 6400.141(c)(11) | The physical examination completed on 5/14/2024 for Individual #1 did not document an assessment of the individual's health maintenance needs, medication regimen and the need for bloodwork at recommended intervals (area for this information on the physical examination form was blank).
NOTE: The physical examination completed on 5/14/2024 is the most current for the individual; the individual has been hospitalized since 4/08/2025 and has not been able to complete a physical examination. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | The site manager shall review all medical appointments forms (including the individuals Annual physical Forms) and after visits summaries for accuracy and follow up instructions. The agency contacted the PCP to complete physical form in its entirety. |
05/25/2025
| Implemented |
| 6400.141(c)(12) | The physical examination completed on 5/14/2024 for Individual #1 did not document physical limitations for the individual (area for this information on the physical examination form was blank).
NOTE: The physical examination completed on 5/14/2024 is the most current for the individual; the individual has been hospitalized since 4/08/2025 and has not been able to complete a physical examination. | The physical examination shall include: Physical limitations of the individual. | The site manager shall review all medical appointments forms (including the individuals Annual physical Forms) and after visits summaries for accuracy and follow up instructions. The agency contacted the PCP to complete physical form in its entirety. |
05/25/2025
| Implemented |
| 6400.141(c)(14) | The physical examination completed on 5/14/2024 for Individual #1 did not document medical information pertinent to diagnosis and treatment in case of emergency (area for this information on the physical examination form was blank).
NOTE: The physical examination completed on 5/14/2024 is the most current for the individual; the individual has been hospitalized since 4/08/2025 and has not been able to complete a physical examination. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The site manager shall review all medical appointments forms (including the individuals Annual physical Forms) and after visits summaries for accuracy and follow up instructions. The agency contacted the PCP to complete physical form in its entirety. |
05/25/2025
| Implemented |
| 6400.151(c)(2) | Staff #1 was hired on 10/30/2023 and there was no documentation in the staff record to indicate that the staff completed a tuberculin skin test, or if tuberculin skin testing was positive, an initial chest x-ray with results noted. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | The agency shall ensure all physical examination meets the requirements including Tuberculin Skin Test. |
05/25/2025
| Implemented |
| 6400.34(a) | 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. Individual #1 was informed of their individual rights on 8/11/2023, then not again until 1/16/2025. | 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. | The agencys' program specialist and site managers shall ensure the individuals consent forms including the individuals rights forms are signed by the individuals every year and stored in their records binder. |
05/25/2025
| Implemented |
| 6400.169(a) | Documentation was not available to show that Staff #1 successfully completed a Department-approved medication administration 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). | The agency's trainer and site manger will ensure staff training records are tracked and filed accordingly and shall be readily available upon request. |
05/25/2025
| Implemented |