| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self-assessments were to be completed between 10/23/24-1/23/25 and/or 10/11/24-1/11/25) and the self-assessment for this home was completed 1/13/25-1/24/25. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter. | Since the timeframe for the submission of the 2024 self-assessment has passed, the agency can not correct this specific violation. The plan to maintain compliance outlines the plan for prevention and future compliance. |
04/23/2025
| Accepted |
| 6400.151(c)(3) | For staff #3, the 8/7/24 physical exam does not indicate if this staff person 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. | Staff #3 was scheduled for a physical from the agency's preferred provider, Concentra. The authorization is from 4/22/2025 and to be completed no later than 05/02/2025. The results should be received no later than 5/5/2025. |
05/05/2025
| Accepted |
| 6400.181(a) | Individual #1's new admission assessment was completed on 2/19/25 which was not completed within 60 days of the individual's date of admission of 12/19/24. | 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. | This violation cannot be rectified as the timeline for compliant submission has passed; this was submitted outside of that window. |
04/23/2025
| Accepted |
| 6400.18(b)(2) | There were eleven occurrences that Individual #1 was not administered their medications, and an incident report was not initiated:
1/16/25 and 1/17/25 8am dose of Farxiga 10 mg
1/18/25 8 am and 12 pm doses of Clonazepam 1 mg
1/19/25 8 am dose of Divalproex 500mg
1/29/25 8 pm dose of Propranolol 10 mg
2/2/25 8 pm dose of Haloperidol 2 mg
2/13/25 4 pm doses of Gabapentin 400 mg and Metformin 1,000 mg
2/14/25 8 am and 12 pm doses of Clonazepam 1 mg (signed, not given)
2/28/25 8 pm doses of Divalproex 500 mg, Lamotrigine 150 mg, Lithium Carbonate 300 mg, Propranolol 10 mg, Benztropine 1 mg, Clonazepam 1 mg, Gabapentin 400 mg, Haloperidol 2 mg, Melatonin 3 mg, and Trazadone 100 mg | 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 72 hours of discovery by a staff person:
A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner. | This medication error occurred in the past and cannot be corrected. EIMs have been entered for the occurrences of medication administration errors. Verifiable documentation errors have been corrected. |
05/01/2025
| Accepted |
| 6400.34(a) | Individual #1 was not informed of right 33b on the 1/29/25 Individual Rights form. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | The Individuals Rights' acknowledgement was updated by the Lead Program Specialist. This was then distributed to each program, to be reviewed by the individuals with the RS or Lead Program Specialist and then signed and filed. |
04/28/2025
| Accepted |
| 6400.167(a)(1) | There were eleven occurrences that Individual #1 was not administered their medications:
1/16/25 and 1/17/25 8am dose of Farxiga 10 mg
1/18/25 8 am and 12 pm doses of Clonazepam 1 mg
1/19/25 8 am dose of Divalproex 500mg
1/29/25 8 pm dose of Propranolol 10 mg
2/2/25 8 pm dose of Haloperidol 2 mg
2/13/25 4 pm doses of Gabapentin 400 mg and Metformin 1,000 mg
2/14/25 8 am and 12 pm doses of Clonazepam 1 mg (signed, not given)
2/28/25 8 pm doses of Divalproex 500 mg, Lamotrigine 150 mg, Lithium Carbonate 300 mg, Propranolol 10 mg, Benztropine 1 mg, Clonazepam 1 mg, Gabapentin 400 mg, Haloperidol 2 mg, Melatonin 3 mg, and Trazadone 100 mg | Medication errors include the following: Failure to administer a medication. | This medication error occurred in the past and cannot be corrected. EIMs have been entered for the occurrences of medication administration errors. Verifiable documentation errors have been corrected. |
05/01/2025
| Accepted |
| 6400.167(d)(1) | Individual #1 was prescribed Penicillin 500mg 1 tab twice daily for 10 days and was given the medication December 31, 2024- January 9, 2025, for the 8 am and 8 pm doses; however, it is documented that an extra dose was administered on Jan 10 at 8 pm. | A medication error shall be reported to the prescriber under any of the following conditions: As directed by the prescriber. | This medication error occurred in the past and cannot be corrected. EIMs have been entered for the occurrences of medication administration errors. Verifiable documentation errors have been corrected. |
05/01/2025
| Accepted |
| 6400.213(1)(i) | Individual #1's record did not include if the individual had any identifying marks. | Each individual's record must include the following information: Race, height, weight, hair color, eye color, and identifying marks. | This violation was addressed during the inspection by the Lead Program Specialist. |
04/25/2025
| Accepted |
| 6400.141(d) | The TB test that was completed on 7/25/23 for Individual #1 does not indicate the results of the test when it was read on 7/27/23 and did not have a signature of the person reading the test. | Immunizations, vision and hearing screening and tuberculin skin testing may be completed, signed and dated by a registered nurse or licensed practical nurse instead of a licensed physician, certified nurse practitioner or licensed physician's assistant. | Individual #1 is scheduled for a PCP appointment on 4/28/2025. At this appointment, their blood will be drawn for a blood TB test. The results will be added to his file when made available. |
05/02/2025
| Accepted |