| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.76(a) | The dresser in Individual 3's bedroom has two (2) broken drawers. | Furniture and equipment shall be nonhazardous, clean and sturdy. | A new dresser was ordered for individual's bedroom due to be delivered between 11/16/2025 & 11/23/2025. |
10/16/2025
| Implemented |
| 6400.143(a) | Individual 3 refuses prostate exams and there was no documentation of training regarding the need for prostate exams. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | Individual 3 has been trained/educated on the importance of routine prostate exams. |
11/14/2025
| Implemented |
| 6400.144 | Individual 3 did not keep their follow-up dental appointment on 01/20/25. | 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.
| Individual 3 has put in a request with his dentist's office to receive a copy of his 01/20/2025 visit paperwork. Individual 3 recalls making the dental appointment, so Rehoboth is working with him to secure the documentation for that visit, to have on file. |
11/14/2025
| Implemented |
| 6400.181(a) | The most recent assessment for individual 3 was completed on 05/02/25 and the assessment completed before that was dated 03/03/24. | 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. | A reminder has been set on the company's calendar to completed individual 3's assessment on or before 05/02/2026. |
11/14/2025
| Implemented |
| 6400.216(a) | Medical Appointment Paperwork for Individual 3 is being kept in an unlocked cabinet next to the kitchen refrigerator. | An individual's records shall be kept locked when unattended.
| Medical Appointment Paperwork has been taken out of the unlocked cabinet and is now kept in Rehoboth's office behind lock & key. |
10/17/2025
| Implemented |
| 6400.18(i) | Incident ID 9676727 with a discovery date of 08/16/25 had no request for an extension until 10/17/25. | The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension. | Incident 9676727 has been submitted within the timeframe of the extended deadline. |
10/21/2025
| Implemented |
| 6400.165(c) | For Individual 3, Albuterol HFA Proair Inhaler (Inhale 2 puffs every 4 hours as needed for wheezing or shortness of breath; prescribed by physician) was found in his medication box; however, it does not appear on the MAR. | A prescription medication shall be administered as prescribed. | Albuterol HFA Proair inhaler with instructions to inhale 2 puffs every 4 hours as needed has been discounted as the current instruction is to inhale 2 puffs every 6 hours. All medications with the outdated instructions have been taken out of the med box and properly disposed of. |
10/17/2025
| Implemented |
| 6400.166(a)(9) | Individual 3 is prescribed Oxycodone Acetaminophen 5-325. The medication label includes instructions to administer 1 tablet by mouth every 4 to 6 hours as needed; however, the MAR did not include any written instructions pertaining to frequency (4-6 hours). | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | Individual 3's MAR now includes the diagnosis, purpose & usage directions of Oxycodone Acetaminophen 5-325, making sure the medication label & MAR match. |
10/20/2025
| Implemented |
| 6400.166(a)(11) | Individual 3 is prescribed Oxycodone Acetaminophen 5-325. The medication label and MAR did not include the diagnosis or purpose of the medication. | 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. | Individual 3's MAR now includes the diagnosis, purpose & usage directions of Oxycodone Acetaminophen 5-325. |
11/14/2025
| Implemented |
| 6400.181(f) | The annual assessment for individual 3 was not forwarded to the ISP team at least 30 days prior to the 05/01/25 ISP team meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | A reminder has been set on the company's calendar to forward individual 3's annual assessment to the ISP team at least 30 days prior to the next ISP meeting. |
10/24/2025
| Implemented |