| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Two (2) one-quart cans of high gloss paint were found in the kitchen cabinets. Both cans were relocated to a locked closet at the time of inspection. Individual #1's ISP states, "It is unknown if (they) would digest poisonous substances in the event of (them) having suicidal ideations. Poisonous materials are kept locked per regulations." | Poisonous materials shall be kept locked or made inaccessible to individuals. | - Immediate corrective action: All paint and other hazardous/poisonous materials were removed from kitchen cabinets and secured in a locked closet during the inspection.
- System fix: A full-house environmental sweep was completed to confirm all chemicals, paints, and similar materials are locked/inaccessible (including maintenance closets, laundry, bathrooms, and under-sink areas).
- Staff instruction: Staff on duty were immediately coached on acceptable storage locations and the requirement to keep poisonous materials locked at all times. |
12/31/2025
| Implemented |
| 6400.68(b) | The hot water in the kitchen sink measured at 124.9°, and the hot water in the bathroom measured 126°; both of which exceed the 120° maximum and 2-degree variance outlined in the RCG. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | - Immediate corrective action: Maintenance request was made to adjust hot water heater/mixing valve settings to reduce hot water output; staff were instructed to monitor for scald risk until verification was complete.
- Verification: Water temperatures were re-checked using a calibrated thermometer at the bathroom tub/shower and sinks to confirm temperatures at or below 120°F.
- Repairs (if needed): If temperatures could not be stabilized through adjustment a request will be made to repair the valve for the hot water heater. |
12/31/2025
| Implemented |
| 6400.71 | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not posted on or near the office telephone. Emergency numbers were posted on the living room wall by the front window; however, a telephone was not located in the living room, dining room, or kitchen areas. | 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.
| - Immediate corrective action: Laminated emergency number sheets (hospital, police, fire, ambulance, poison control) were posted directly next to the office telephone with an outside line.
- Access improvement: A telephone with an outside line was placed in a common area (kitchen/dining) or
emergency numbers were posted next to any additional outside-line telephones used by staff. |
12/22/2025
| Implemented |
| 6400.72(a) | No screen was found in the office window located to the right of the office desk. The window is able to be opened
No screens were found in the living room window closest to the front door. The windows are able to be opened. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | - Immediate corrective action: The affected windows were kept closed and/or restricted from opening until screens were installed.
- Repair: Replacement screens were measured and ordered; once received, maintenance installed
secure-fitting screens on the identified office and living room windows. |
12/31/2025
| Implemented |
| 6400.81(k)(6) | Individual #1's bedroom was not equipped with a mirror. The ISP does not indicate an exception to the regulatory requirement. | In bedrooms, each individual shall have the following: A mirror. | - Immediate corrective action: Individual restriction plan includes removal of breakable objects from their room due to suicidal ideations.
- Documentation: A copy of the restriction plan has been placed in apartment.
- Staff guidance: Staff were reminded that required bedroom furnishings must be in place unless an ISP
documents a specific exception. |
12/22/2025
| Implemented |
| 6400.144 | Individual #1 is prescribed Norethindron Tab 0.35% Oral Contraceptive (take 1 tablet by mouth daily at 8:00 am). This medication was listed on the December 2025 MAR; however, was not available in the home.
Individual #1 was prescribed Ofloxacin 0.3% Op Solution (instill 10 drops to the right ear daily at 8am for infection for 7 days). The medication was dispensed 11/19/25 as a time-limited medication, and no longer appears on the MAR. Per staff, the medication is not being offered; however, there is no discontinuation order on file, and no documentation was available to support that the infection was resolved. | 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.
| - Immediate corrective action: Medication reconciliation was completed with the pharmacy and prescriber(s). Any active medications missing from the home were obtained the same day via pharmacy delivery or pickup.
- Prescriber documentation: The prescriber was contacted to obtain written clarification: (a) whether the
Ofloxacin course was completed and should be discontinued, and (b) whether follow-up was required to confirm infection resolution. Written orders/notes were filed in the individual's record.
- MAR correction: The MAR was updated to match current prescriber orders and pharmacy profile. Any
discontinued/time-limited medications were clearly documented with start/stop dates and discontinuation orders.
- Nursing oversight: The agency RN completed a targeted medication management review and provided staff coaching on medication reconciliation, time-limited medications, and required documentation. |
12/29/2025
| Implemented |
| 6400.18(a)(5) | Incident 9742562 for Individual #1 was created on 12/3/2025. The discovery date was 11/26/2025. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Neglect.
| - Immediate corrective action: The incident was reviewed by the Program Specialist/Program Manager and Administrative staff to confirm event details and ensure the report includes complete, accurate information, including the correct discovery date and narrative context.
- Root cause analysis: Management identified a gap in staff understanding of what constitutes 'discovery' and the escalation steps for time-sensitive reportable incidents.
- Training and accountability: All direct support professionals and site leadership were re-trained on 6400 incident reporting timelines and 'discovery' definition, with emphasis on neglect reporting within 24 hours. Competency is documented via sign-in and post-training knowledge check. Coaching/disciplinary action will occur when late reporting is confirmed. |
12/29/2025
| Implemented |
| 6400.165(c) | For Individual #1, the following medication was found in the home; however, was not listed on the MAR: Lo-Zumandimi 3-0 .02mg oral contraceptive tablet (take by mouth daily at 8am). | A prescription medication shall be administered as prescribed. | - Immediate corrective action: Medication reconciliation was completed to determine whether the medication is an active order. Staff were instructed not to administer any medication not present on the MAR until the MAR was corrected/confirmed by the prescriber/pharmacy record.
- MAR update or removal: If active, the medication was added to the MAR with correct dose/time and verified against the prescription label and/or pharmacy profile. If not active, the medication was removed from use and disposed/returned per pharmacy guidance and provider policy, with documentation of removal.
- Staff coaching: Staff were re-trained that the MAR must match current orders, and medications in the home must be reconciled immediately when new medications arrive or when the MAR changes. |
12/29/2025
| Implemented |
| 6400.165(e) | Individual #1 is regularly refusing medications. A medication review was completed on 12/05/25 at 9:25 am. At the time of the review, 8:00 am medications had not been administered, and a medication refusal was not noted. In speaking with the three (3) staff present, 8:00 am medications are offered to Individual FC beginning at 8:00 am, and as late as 10:00-11:00am. If Individual is compliant, morning medications are then dispensed after the allowable window of one hour before, to one hour after the prescribed time. This same practice is in place for afternoon and evening medications. Per staff, this was agreed upon by the prescribing doctors and agency Nurse during a Team Meeting; however, there is no documentation on record to support the changes to administration times (See RCG pg 101-102). | Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received. | - Immediate corrective action: The RN/management contacted prescribers to request written orders for any needed administration time changes (for example, to address frequent refusals). Once received, orders were filed and MAR updated immediately.
- Refusal documentation: Staff were re-trained and required to document each offer/refusal on the MAR at the time it occurs, including reason (if offered) and follow-up actions.
- Targeted competency review: Medication administration observations were completed for staff responsible for med passes, focusing on timing windows and refusal documentation. |
12/29/2025
| Implemented |