| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.77(b) | There was no thermometer found in the First Aid Kit. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | The thermometer had been temporarily removed from the home's First Aid Kit for use during a minor illness and was not returned afterward. Staff failed to replace it immediately or notify the Program Manager that it was missing.
Corrective Action Taken:
Staff confirmed all items required were present including thermometer. A photo of the complete First Aid kit was sent to the Program Manager as verification. |
10/06/2025
| Implemented |
| 6400.141(a) | Annual physical on file dated 8/29/2025. Individual #2 was admitted on 5/21/2025 | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | An annual physical is on file dated 8/29/2025. However, Individual #2 was admitted on 5/21/2025, meaning there was no physical on file within 12 months prior to admission or within 30 days of admission, as required. A process is already in place to verify that each individual has a current physical exam prior to or within 30 days of admission. However, during the admission process for Individual #2, this step was inadvertently overlooked. |
10/06/2025
| Implemented |
| 6400.144 | Tylenol was available as a PRN but was not present on the MAR for Individual #2. | 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.
| The PRN Tylenol was delivered by the pharmacy and available in the home, but staff did not update the MAR when the medication was received. The oversight occurred due to a lapse in communication between the pharmacy delivery and documentation process.
The Tylenol was immediately added to the MAR with the correct dosage and PRN instructions. The RN reviewed the medication and confirmed that the MAR accurately reflects the prescription label. Staff involved were reminded to check for new medications and ensure the MAR is updated the same day medications are delivered. |
09/19/2025
| Implemented |
| 6400.151(a) | Staff Person #1's physical was last completed 5/12/2023. This Staff Person does not have an additional physical on file. | 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. | Tracking system for staff health documentation did not generate a reminder for upcoming renewals, resulting in the oversight. Staff Person #1 completed a new physical exam on 9/22/2025. The updated form was placed in the personnel file and reviewed for all required components under §6400.151(b). |
09/19/2025
| Implemented |