| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | On 2/13/2025 at 2:56PM, a bottle of Clorox Bleach was unlocked and accessible on a shelf in the basement of the home. On 2/13/2025 at 3:01PM, a spray bottle of Clorox Cleaner with Bleach and a spray bottle of Awesome Cleaner was unlocked and accessible in the cabinet under the sink in the bathroom on the second floor of the home. Individual #1's service plan, last updated 1/30/2025, reads, "[Individual #1] DOES KNOW NOT TO INGEST POISONOUS SUBSTANCES AND TO BE CAREFUL AROUND DANGEROUS OBJECTS, BUT AT TIMES [Individual #1] OFTEN DOES THINGS WITHOUT THINKING ABOUT THE END RESULT AND MAY PUT [SELF] IN DANGER WITHOUT CLOSE SUPERVISION. POISONOUS SUBSTANCES ARE KEPT OUT OF REACH OF [Individual #1]. [Individual #1] IS EXTREMELY IMPULSIVE." | Poisonous materials shall be kept locked or made inaccessible to individuals. | To immediately correct the issue, all unsecured cleaning products and poisonous materials were removed and properly locked up on the same day of the inspection by Director of Operations. Staff were instructed by DoO to conduct a full home sweep to verify that all hazardous materials were properly stored. |
02/14/2025
| Not Implemented |
| 6400.63(a) | On 2/13/2025 at 2:45PM, the hot water temperature measured 122.9°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 2/13/2024 at 2:50PM, three pieces of the ceramic tile were broken at the edge of the top landing of the interior stairs leading to the basement posing a tripping hazard. | Floors, walls, ceilings and other surfaces shall be in good repair. | To correct this issue, the Director of Operations has scheduled the Maintenance Team to come out and make the necessary repairs, which will be completed by March 16, 2025. In the meantime, the affected area has been clearly marked as a hazard to prevent accidents until repairs are finalized and the individual has been asked to avoid this area until repairs are made. |
03/16/2025
| Not Implemented |
| 6400.68(b) | On 2/13/2025 at 3:00PM the hot water temperature measured 124.5°F 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 |
| 6400.73(a) | On 2/13/2025 at 4:22PM, the railing attached to the eight, exterior, cement stairs in the front of the home was not well secured and moved back and forth while in use. [Repeat Violation, 2/13/2024] | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | To correct this issue, the Maintenance Team was assigned to reinforce and secure the railing, ensuring it is stable and safe for use. The repair will be completed by March 16, 2025, and the railing will be inspected to confirm compliance with safety standards immediately after. |
03/26/2025
| Not Implemented |
| 6400.76(a) | On 2/13/2025 at 4:00PM, three chairs at the table in the dining room of the home were not sturdy and wobbled when in use. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The three chairs at the table in the dining room were secured by tightening loose screws on the day of inspection by Director of Operations. |
02/14/2025
| Not Implemented |
| 6400.101 | On 2/13/2025 at 3:15PM, there was a padlock on door in the leading to a storage room in basement of the home. On 2/13/2025 at 3:17PM, there was a slide chain lock on the basement side of the door leading to the attached garage of the home; posing an obstruced egress from the garage when engaged. There is no swing door in the garage. [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 Director of Operations removed the padlock locks and slide chain locks from all doors on the day of inspection to prevent potential obstruction. Additionally, the Maintenance Team, under the oversight of the Program Director, will replace all locks with one that is compliant by March 16, 2025. |
03/16/2025
| Not Implemented |
| 6400.114(b) | The provider agency's smoking policy reads, "all smoking materials, including cigarettes and e-cigarettes, must be disposed of responsibly in provided cigarette receptacle. Improper disposal, such as littering or leaving smoking materials unattended, is unacceptable and may lead to disciplinary action." On 2/13/2025 at 2:47PM, a plastic, disposable water bottle containing partially smoked cigarettes and cigarette butts were on the ground next to the smoking receptacle on the cement patio in the rear of the home. | Written smoking safety procedures shall be followed. | To correct this issue, all staff have been retrained on the agency's smoking policy, emphasizing that all smoking materials, including cigarettes and e-cigarettes, must be disposed of properly in the designated receptacle. A staff meeting was held on February 19, 2025 to review expectations and the potential disciplinary actions for non-compliance. |
02/19/2025
| Implemented |
| 6400.151(a) | Direct Service Worker #2, date of hire 1/20/2025, began working with individuals on 1/25/2025. Direct Service Worker #2's most recent physical examination was completed on 4/1/2022. | 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 at 2:52PM, there was a thumbnail lock on 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 Director of Operations, will remove the thumbnail lock and replace it with a compliant lock. A key will be provided to the individual and the staff member on shift to ensure proper access. This corrective action was started February 27, 2025 and will be completed on March 16, 2025. |
03/16/2025
| Not Implemented |
| 6400.32(r)(5) | On 2/13/2025 at 2:52PM, there was a thumbnail lock on door leading to Individual #1's bedroom. Staff does 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 Director of Operations, will remove the thumbnail lock and replace it with a compliant lock. A key will be provided to the individual and the staff member on shift to ensure proper access. This corrective action was started February 27, 2025 and will be completed on March 16, 2025. |
03/16/2025
| Not Implemented |
| 6400.34(a) | Individual #1 was informed and explained individual rights on 1/10/2025. 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(d) | Direct Service Worker #1, who first worked with individuals 1/10/2025, did not complete training on basic first aid. | 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. | 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 |
| 6400.163(d) | On 2/13/2025 at 2:49PM, the first aid kit containing four, single dose packets of Ibuprofen; four, single dose packets of Non-Aspirin; and three, single dose packets of Antacid was unlocked and accessible in the cabinet above the refrigerator in the kitchen of the home. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | To correct this issue, the Director of operations removed any OTC medication from the first aid kit immediately. Additionally, all staff members were reminded of proper medication storage protocols and instructed that all medications must be locked at all times unless in immediate use and over-the-counter medications are not permitted. |
02/19/2025
| Not Implemented |
| 6400.163(h) | Individual #1 was prescribed Ibuprofen 800MG on 1/25/2025, with instructions to, "Take one tablet three times a day by oral route for 10 days." This medication should have been discontinued on 2/4/2025. On 2/13/2025 at 3:23PM, the Ibuprofen 800MG remained in Individual #1's medication box. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | 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. The updated information will be entered into the electronic Medication Administration Record (eMAR) system to maintain accuracy. Additionally, an incident was entered in the EIM and APS contacted to report neglect failure to provide medication management. |
02/19/2025
| Not Implemented |
| 6400.166(a)(11) | Individual #1's February Medication Administration Record did not include the diagnosis or purpose for Risperidone, Vitamin D3, Trazodone HCL, Olanzapine 5MG, Olanzapine 20MG, Omeprazole, Prazosin, Divalproex, Propranolol, Docusate and Levothyroxine. | 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 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. The updated information will be entered into the electronic Medication Administration Record (eMAR) system to maintain accuracy. |
02/19/2025
| Not Implemented |
| 6400.166(d) | Individual #1 was prescribed Penicillin V Potassium 500MG with instructions to, "take one tablet every 6 hours by oral route for seven days." This medication was first administered on 1/25/2025 at 8:00PM and continued until 8:00AM on 2/3/2025. This order for Penicillin V Potassium should have ended on 2/1/2025. Individual #1 was prescribed Ibuprofen 800MG with instructions to, "Take one tablet three times a day by oral route for ten days." This medication was first administered at 8:00PM on 1/25/2025 and continued until 2:00PM on 2/7/2025. This order for Ibuprofen 800MG should have been ended on 2/4/2025. | The directions of the prescriber shall be followed. | 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. The updated information will be entered into the electronic Medication Administration Record (eMAR) system to maintain accuracy. Additionally, an incident was entered in the EIM and APS contacted to report neglect failure to provide medication management. |
02/19/2025
| Not Implemented |
| 6400.169(a) | Direct Service Worker #2, date of hire 1/20/2025, did not complete Medication Administration Training. Direct Service Worker #2 administered Individual #1's medications at 8:00PM on 2/5/2025. | 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 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. If the staff member does not pass the medication administration course before engaging with the individual, they will not be allowed to pass medication. The second med trained staff will be the one to administer meds. The DSP is currently undergoing med training and is not allowed to pass medication until completion of the course. |
02/17/2025
| Not Implemented |