| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.65 | On 4/7/2026 at 2:45PM, there was no mechanical ventilation or window in the bathroom in the basement of the home. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| ON 04/10/2026 A MECHANICAL VENTILATION FAN WAS INSTALLED IN THE BATHROOM IN THE BASEMENT. The fan has been restored to proper working condition to ensure adequate air circulation and compliance with regulatory standards. |
04/10/2026
| Implemented |
| 6400.181(e)(1) | Individual #1's assessment, completed 6/27/2025, does not include the individual's preferences. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | On 4/09/2026 The program specialist reviewed and updated individual# 1 assessment to include the individual preference. The updated assessment has been incorporated into the individual's record and communicated to the appropriate team members to ensure the information is reflected in the individual's services and supports. |
04/09/2026
| Implemented |
| 6400.181(e)(2) | Individual #1's assessment, completed 6/27/2025, does not include dislikes. | The assessment must include the following information: The likes, dislikes and interest of the individual. | On 4/09/2026 The program specialist reviewed and updated individual# 1 assessment to include the individual dislikes. The updated assessment has been incorporated into the individual's record and communicated to the appropriate team members to ensure the information is reflected in the individual's services and supports. |
04/09/2026
| Implemented |
| 6400.214(b) | On 4/7/2026 at 2:45PM, Individual #1's psychological evaluation was not present in the home. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| On 4/8/2026 the program specialist immediately obtained and placed a current copy of the individual's psychological evaluation in the home. |
04/08/2026
| Implemented |
| 6400.166(a)(13) | Individual #1's April 2026 Medication Administration Record did not include the name of Direct Service Worker #1. Direct Service Worker #1 Administered all medications to Individual #1 on 4/1/2026 at 9AM, 12PM, 5PM and 9PM. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | On 4/9/2026 the program specialist reviewed and corrected to include the name and required identification of Direct Support Worker #1 for all applicable medication administration entries. The correction was made in accordance with proper documentation standards to ensure accuracy and compliance. On 4/9/26 The staff involved was promptly retrained on MAR documentation requirements. |
04/09/2026
| Implemented |
| 6400.166(d) | Individual #1 is prescribed Levothyroxine 20MG with instructions to, "Take one tablet by mouth every morning on an empty stomach; avoid food and other medications for 30 minutes after taking-for Hypothyroid," and Lurasidone HCL 20MG with instructions to, "Take one tablet by mouth every day at 9AM with at least 350 calories of food for mood disorder." Individual #1's Medication Administration Record documents that these medications, along with several other medications, are being administered together. | The directions of the prescriber shall be followed. | On April 8, 2026, The Program Specialist immediately reviewed Individual #1's complete medication regimen and all associated physician's orders to ensure full understanding of all administration requirements and to identify any additional discrepancies.
The Medication Administration Record (MAR) has been corrected to accurately reflect the proper administration time for Levothyroxine specifically, that it must be administered 30 minutes before all other medications and food, in accordance with the prescribing physician's orders.
A dedicated documentation sheet has been established to verify and record that Lurasidone is being administered with a minimum of 350 calories of food, as prescribed by the physician. This documentation sheet will be maintained as part of the individual's medication administration records.
All staff responsible for medication administration have been educated and trained on the corrected Levothyroxine administration time change as reflected on the updated MAR, ensuring awareness of the 30-minute interval requirement prior to other medications and food.
All staff responsible for medication administration have been educated and trained on the specific medication administration requirements for Lurasidone, including the 350-calorie food requirement, and have been instructed on the proper use of the newly established documentation sheet. |
04/08/2026
| Implemented |