| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.104 | Notification letters to the fire department were maintained in the fire safety books of all homes on the license, however they did not contain the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. Notification letters were not kept current and updated as census numbers changed in the homes. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| All correspondence pertaining to each residence has been updated in accordance with applicable regulations. These letters have been dispatched to each fire department via email or traditional mail. |
12/24/2024
| Implemented |
| 6400.110(f) | Individual #1 is documented as having a hearing impairment and recommended to be fitted for hearing aids. The home does not have smoke detectors and fire alarms that are equipped so that Individual #1 will be alerted in the event of a fire. | If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. | A networked smoke detection system has been installed for individual #1. This system comprises a smoke alarm transmitter, an alarm clock receiver, and a building night light, in addition to a bed shaker positioned near the bed. The bed shaker has undergone a compliance assessment to confirm that it effectively alerts individual #1 in the event of a fire emergency. |
12/23/2024
| Implemented |
| 6400.181(e)(13)(i) | Individual #1's annual assessment dated 10/2/24 did not assess Individual #1's progress and growth in over the past 365 days in the area of health. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| The Program Specialist has revised the assessment for individual #1, incorporating a section specifically focused on Health. This section will provide detailed commentary on the individual's progress related to Health outcomes every 365 days on progress related to health. The revised assessment has been submitted to affirm that the necessary corrective actions have been implemented. |
12/27/2024
| Implemented |
| 6400.181(e)(13)(ii) | Individual #1's annual assessment dated 10/2/24 did not assess Individual #1's progress and growth in over the past 365 days in the area of motor and communication skills. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | The Program Specialist has revised the assessment for individual #1, incorporating a section specifically focused on Motor and Communication Skills. This section will provide detailed commentary on the individual¿s progress related to Motor and Communication Skills outcomes every 365 days on progress related to Motor and Communication Skills. The revised assessment has been submitted to affirm that the necessary corrective actions have been implemented. |
12/27/2024
| Implemented |
| 6400.181(e)(13)(iii) | Individual #1's annual assessment dated 10/2/24 did not assess Individual #1's progress and growth in over the past 365 days in the area of activities of residential living. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | The Program Specialist has revised the assessment for individual #1, incorporating a section specifically focused on Activities of Residential Living. This section will provide detailed commentary on the individual¿s progress related to Activities of Residential Living outcomes every 365 days on progress related to Activities of Residential Living. The revised assessment has been submitted to affirm that the necessary corrective actions have been implemented. |
12/27/2024
| Implemented |
| 6400.181(e)(13)(iv) | Individual #1's annual assessment dated 10/2/24 did not assess Individual #1's progress and growth in over the past 365 days in the area of personal development. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | The Program Specialist has revised the assessment for individual #1, incorporating a section specifically focused on Personal Development. This section will provide detailed commentary on the individual¿s progress related to Personal Development outcomes every 365 days on progress related to Personal Development. The revised assessment has been submitted to affirm that the necessary corrective actions have been implemented. |
12/27/2024
| Implemented |
| 6400.181(e)(13)(v) | Individual #1's annual assessment dated 10/2/24 did not assess Individual #1's progress and growth in over the past 365 days in the area of socialization. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | The Program Specialist has revised the assessment for individual #1, incorporating a section specifically focused on Socialization. This section will provide detailed commentary on the individual¿s progress related to Socialization outcomes every 365 days on progress related to Socialization. The revised assessment has been submitted to affirm that the necessary corrective actions have been implemented. |
12/27/2024
| Implemented |
| 6400.181(e)(13)(vi) | Individual #1's annual assessment dated 10/2/24 did not assess Individual #1's progress and growth in over the past 365 days in the area of recreation. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | The Program Specialist has revised the assessment for individual #1, incorporating a section specifically focused on Recreation. This section will provide detailed commentary on the individual¿s progress related to Recreation outcomes every 365 days on progress related to Recreation. The revised assessment has been submitted to affirm that the necessary corrective actions have been implemented. |
12/27/2024
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's annual assessment dated 10/2/24 did not assess Individual #1's progress and growth in over the past 365 days in the area of financial independence. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| The Program Specialist has revised the assessment for individual #1, incorporating a section specifically focused on Financial Independence. This section will provide detailed commentary on the individual¿s progress related to financial Independence outcomes every 365 days on progress related to Financial Independence. The revised assessment has been submitted to affirm that the necessary corrective actions have been implemented. |
12/27/2024
| Implemented |
| 6400.181(e)(13)(viii) | Individual #1's annual assessment dated 10/2/24 did not assess Individual #1's progress and growth in over the past 365 days in the area of managing personal property. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | The Program Specialist has revised the assessment for individual #1, incorporating a section specifically focused on Managing Personal Property. This section will provide detailed commentary on the individual¿s progress related to Managing Personal Property outcomes every 365 days on progress related to Managing Personal Property. The revised assessment has been submitted to affirm that the necessary corrective actions have been implemented. |
12/27/2024
| Implemented |
| 6400.181(e)(13)(ix) | Individual #1's annual assessment dated 10/2/24 did not assess Individual #1's progress and growth in over the past 365 days in the area of community integration. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration. | The Program Specialist has revised the assessment for individual #1, incorporating a section specifically focused on Community integration. This section will provide detailed commentary on the individual¿s progress related to Community integration outcomes every 365 days on progress related to Community integration. The revised assessment has been submitted to affirm that the necessary corrective actions have been implemented. |
12/27/2024
| Implemented |
| 6400.214(b) | Individual records with the most current information are not maintained in the home for all individuals. Individual records with are maintained at the provider's office. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| The program specialist created a duplicate individual record that has been placed in each individual's home. Individual records were placed in the home on 12/20/2024. |
12/20/2024
| Implemented |
| 6400.51(b)(5) | Staff #1 and Staff #2 did not receive orientation training in job related skills and knowledge specifically in the safe and appropriate use of behavior supports if the person works directly with an individual. | The orientation must encompass the following areas: Job-related knowledge and skills. | Staff members #1, and #2 received comprehensive training regarding the safe and appropriate application of behavioral support techniques. Documentation of their training has been uploaded for verification purposes. |
12/27/2024
| Implemented |
| 6400.52(c)(3) | Staff#1 was not trained annually in the area if Individual Rights. Staff #1 was trained on Individual Rights on 7/24/23 and was not trained again until 10/7/24. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | The training has already been completed on 10/07/2024. The provider will ensure that subsequent training sessions occur at intervals not exceeding 12 months from the most recent training. |
12/27/2024
| Implemented |
| 6400.165(c) | Medications are not administered as prescribed. Individual #1 is prescribed Flonase .05% nasal spray, 2 sprays into each nostril once daily at 8am. The bottle of this medication contains 120 metered sprays, each individual spray consisting of one metered spray when administered. Based on the dosing instructions and number of metered sprays in the bottle, the bottle is a 30-day supply of medication. The medication was last filled on 10/23/24 and contained half a bottle of medication. The medication is documented as administered daily. If the medication was administered daily as prescribed, the bottle would have needed to be refilled in November and would be coming due for a new refill.
Individual #1 is prescribed Woun'dres wound dressing, apply topically to left and right lower leg and cover with island dressing 3 times a day at 8am, 2pm and 8pm. This was not available in the home; however, this was documented as administered from on 12/16/24 at 8am, Individual #1 did not have a dressing on the individual's leg at the time of the inspection. | A prescription medication shall be administered as prescribed. | The pharmacy was contacted regarding the Flonase 0.05% nasal spray, and a new bottle was delivered. The wound dressing was discontinued by the primary care physician (PCP). A new order for the wound dressing was prescribed and delivered. All staff supporting individual #1 were trained in accordance with section 6400.165(C) regarding the failure to administer medication as prescribed on December 27, 2024. |
12/27/2024
| Implemented |
| 6400.166(b) | Individual #1 is prescribed Eliquis 5mg tablet, 1 tablet by mouth twice daily. The medication administration record did not include the name of the person administering the dose for the 8PM on 12/1/24. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Individual #1 MAR has been initialed by the staff in question for 12/01/24 on 12/16/24. |
12/16/2024
| Implemented |