| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Individual #2 is not designated as poison safe. At the time of inspection, the following poisons were found unlocked and accessible within the home:
1. Kitchen, in a cabinet above the refrigerator -- One package of Air Wick Essential Oils fragrance refills and one package of Glade Plugins scented oil refills.
2. Main Bathroom, on the sink countertop -- One bottle of Febreeze Air Mist "Southern Lilac Mornings" air freshener.
3. Master Bathroom, on the sink countertop -- One bottle of Crest Pro-Health Advanced Anti-Cavity Fluoride Mouthwash and one tube of Colgate Total Whitening Toothpaste.
4. Master Bathroom, in a caddy on top of the toilet tank -- One bottle of Equate Everyday Clean 2-in-1 Dandruff Shampoo & Conditioner and one can of Skintimate Skin Therapy Moisturizing Shave Gel. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Team meeting was convened on 6/27/25 and ISP was updated to include continue locking poisonous materials with exception of soaps, mouth was, air refreshers, air sprays, bath lotions, shampoos and other personal hygiene products. The team agreed that the individual is safe around these products and would not ingest them. A copy of ISP excerpt is attached in a separate email. |
06/27/2025
| Implemented |
| 6400.104 | Individual #2 requires assistance to evacuate the home during a fire. A letter notifying the local fire department of this individual's need for assistance was found within the Individual Record; however, as this letter was not dated, it could not be confirmed that the letter was sent to the fire department upon this individual's admission to the home on 11/04/2024. | 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.
| Upon discovery on the day of inspection, the notification letter was updated with a date of 6/24/25 and was sent to the fire department via certified mail on 6/24/2025. The same information was shared with the inspector during the same day of inspection |
06/24/2025
| Implemented |
| 6400.112(c) | The fire drill record for this location's 12/28/2024 overnight fire drill was missing the following required information: the evacuation time for the fire drill. | 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. | Upon discovery, the evacuation time of the fire drill was added to the form on the same day of inspector on 6/24/2025. This information was found in the fire drill spreadsheet tracker |
06/24/2025
| Implemented |
| 6400.165(g) | Individual #2 was prescribed medications to treat the symptoms of psychiatric conditions. The documentation for Individual #2's 11/26/2024, 01/14/2025, and 04/08/2025 psychotropic medication reviews were missing the physician's statement on whether or not there was a need to continue each of the prescribed medications at the time of each visit. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Upon discovery, the provider updated the 3 month review medical case note to capture all required aspects including but not limited to reason for prescribing the medication, the need to continue the medication, required dosage. A copy of the provider's updated medical case note is attached in a separate email. |
06/24/2025
| Implemented |
| 6400.213(1)(i) | Individual #2's Individual Record was missing the following demographic information: The presence or absence of identifying marks. | Each individual's record must include the following information: Personal information, including: (ii) The race, height, weight, color of hair, color of eyes and identifying marks. | Upon discovery on the same day of inspection, the demographic information was updated to include identifying marks on 6/24/2025. This updated information was shared with inspector on the same day of inspection. |
06/24/2025
| Implemented |