| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.111(c) | During inspection, there was no fire extinguisher present in the kitchen. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | Our post inspection showed that there was indeed a fire extinguisher present under in the kitchen sink at the time of the inspection. However, Using a two part self-inspection team, we will used the ODP's provider self assessment tool to perform monthly and quarterly home inspection/self assessment going forward. |
02/28/2026
| Implemented |
| 6400.141(c)(10) | Individual #3's current physical dated 9/11/25 did not include a response to the question, Is the person free of communicable disease? | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | Individual #3 was furnished with a new annual physical with indication that the individual is freed of communicable disease. |
03/02/2026
| Implemented |
| 6400.181(a) | Individual #3's annual assessments dated 9/21/24 and 8/07/25 were entirely identical. Also, the 8/07/25 assessment was completed prior to the full year which would not meet the regulatory standard for a complete assessment period. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Our program specialist was required and did complete new assessments showing up-to-date information. |
03/05/2026
| Implemented |
| 6400.34(b) | Individual #3's record did not include a signed and dated copy of the individual's rights. | The home shall keep a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights. | A new individual rights statement was provided and signed by the individual after the review. |
02/28/2026
| Implemented |
| 6400.163(d) | Individual #3 is prescribed a controlled substance Lorazepam 1 MG Tablet as a PRN, which was not double locked during storage. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | While the door that stores the medication was locked, the actual box containing the medication was not. This was an oversight caused the last med administrator's failure to lock the box. Immediately after the review, the box was locked. |
03/02/2026
| Implemented |
| 6400.165(g) | Individual #3's psychotropic medication reviews for the past year have been inconsistently documented leaving out vital details including the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | 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. | A corrected MAR and pharmacy label was created by the pharmacy that shows the details missing on the previous one. |
03/02/2026
| Implemented |
| 6400.166(a)(11) | Individual #3's MAR nor the blister packs include the diagnosis for the following prescribed medications:
Lorazepam 1 MG Tablet (diagnosis found on MAR not on blister pack)
Sertraline HCL 50 MG Tablet
Benztropine MES 0.5 MG Tablet
Divalproex 500 MG ER Tablet (diagnosis found on MAR not on blister pack)
Divalproex Sod Er 250 MG Tablet | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | A corrected MAR and pharmacy label was created by the pharmacy that shows the details missing on the previous one. |
03/02/2026
| Implemented |