| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | Water temperature registered at 153.5 degrees Fahrenheit at the kitchen sink. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Beyond Care Services acknowledges that the water temperature at the kitchen sink was measured at 153.5°F at the time of inspection. Although the regulation applies specifically to bathtubs and showers, Beyond Care Services recognizes the importance of maintaining safe water temperatures throughout the home.
To correct this issue, Beyond Care Services immediately adjusted the hot water system to ensure that water temperatures in all bathtubs and showers do not exceed 120°F. The water temperature was rechecked following the adjustment to confirm compliance. Documentation of the corrective action has been completed. |
01/05/2026
| Implemented |
| 6400.141(c)(6) | Individual One was admitted on 9/3/25. The pre-admission physical was completed on 3/12/25. However, the last TB test was completed on 1/23/23 which was more than a year prior to admission. A new TB test with a negative result was not completed until the individual had another physical on 10/27/25. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Beyond Care Services acknowledges that although Individual One had a pre-admission physical completed on 3/12/25, the most recent Tuberculin (TB) test on file dated 1/23/23 was not current at the time of admission on 9/3/25. A new TB test with negative results was subsequently completed on 10/27/25 during a follow-up physical.
To correct this noncompliance, Beyond Care Services has verified that Individual One now has a current TB test with documented negative results in the medical record. All required documentation has been placed in Individual One's file to ensure compliance with TB testing requirements. |
01/05/2026
| Implemented |
| 6400.141(c)(14) | The individual One physical completed on 10/27/25 does not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Beyond Care Services acknowledges that the physical examination completed on 10/27/25 for Individual One did not include medical information pertinent to diagnosis and treatment in the event of an emergency.
To correct this issue, Beyond Care Services has obtained updated medical documentation from the appropriate healthcare provider to ensure that all medical information necessary for emergency diagnosis and treatment is accurately documented. The completed documentation has been placed in Individual One's medical record. |
01/05/2026
| Implemented |
| 6400.142(c) | The dental services appointment form located in Individual One's record does not have a date of service on it. | A written record of the dental examination, including the date of the examination, the dentist's name, procedures completed and follow-up treatment recommended, shall be kept. | Beyond Care Services acknowledges that the dental services appointment form in Individual One's record did not include the date of service at the time of review.
To correct this issue, Beyond Care Services obtained the missing date of service from the dental provider and updated the dental services record accordingly. The completed and accurate documentation, including the date of examination, has been placed in Individual One's file. |
01/05/2026
| Implemented |
| 6400.151(c)(3) | Staff One's Physical does not list that she is free from communicable diseases. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | Beyond Care Services acknowledges that Staff One's physical examination did not include a signed statement indicating that the staff member is free from communicable diseases or, if applicable, able to work with specific precautions.
To correct this issue, Beyond Care Services obtained updated medical documentation from the appropriate healthcare provider confirming that Staff One is free from communicable diseases, or outlining any required precautions if applicable. The signed documentation has been placed in Staff One's personnel file. |
01/09/2026
| Implemented |
| 6400.212(a) | Family history information for another individual supported by the agency is incorrectly written in to the family history paragraph of Individual One's Behavior support plan. | A separate record shall be kept for each individual.
| Beyond Care Services acknowledges that information pertaining to another individual supported by the agency was incorrectly included in the family history section of Individual One's Behavior Support Plan.
To correct this issue, Beyond Care Services immediately reviewed and revised Individual One's Behavior Support Plan to remove all information related to any other individual. The document was corrected to ensure that only accurate, individual-specific family history information is included. The updated and corrected Behavior Support Plan has been placed in Individual One's record. |
01/05/2026
| Implemented |