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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.70 | On 4/30/2025 at 10:40AM, the cellular telephone provided by the home was on the dining room table and was not fully charged and required a passcode to operate; therefore, not easily accessible to Individual #1 and Individual #2. There is no landline telephone service in the home. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| What specific change will be made: A landline telephone was installed in the home to ensure 24/7 access to emergency communication. Emergency contact numbers were posted next to the phone in large, easy-to-read print. The cellular phone previously used was removed from the home to eliminate barriers such as passcode access and nightly removal.
Who will make the change: The Facility Compliance Manager coordinated installation of the landline. The House Supervisor ensured emergency numbers were posted and that the cell phone was removed.
When will the change be made: The correction was completed on May 23, 2025.
How will the change be made: The landline was installed in a common area, confirmed to be working, and emergency contacts were clearly posted. The cell phone was removed permanently to prevent future non-compliance. |
05/23/2025
| Implemented |
| 6400.77(b) | On 4/30/2025 at 10:58AM, the home's first aid kit did not contain a thermometer. | 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. | How we plan to correct the non-compliance:
What happened / Why did it happen:
During the inspection on April 30, 2025, the first aid kit in the home did not meet the regulatory requirements outlined in § 6400.77(b). Either the kit was incomplete or the required items (e.g., thermometer, manual, gauze pads) were missing or not verified by staff. This occurred due to lack of a standardized checklist for first aid kit contents and failure to routinely check and replenish supplies.
What specific change was made to fix the problem:
On May 1, 2025, a new first aid kit was placed in the home. The kit was verified to contain all required items:
Antiseptic
Adhesive bandages (assorted)
Sterile gauze pads
Thermometer
Tweezers
Tape
Scissors
Syrup of Ipecac (N/A, as not required for current residents)
First Aid Manual
Who made the change and when:
The Facility Compliance Manager placed the new first aid kit and verified its contents on May 1, 2025.
How was the issue corrected:
The new kit was stocked, labeled, and placed in a clearly marked, easily accessible location in the home. The contents were documented and reviewed against § 6400.77(b) standards. |
05/01/2025
| Implemented |
| 6400.77(c) | On 4/30/2025 at 10:58AM, a first aid manual was not kept with the first aid kit. | A first aid manual shall be kept with the first aid kit. | Provider¿s Plan of Correction (To Immediately Address the Violation):
What Happened / Why It Happened:
On April 30, 2025, at 10:58 AM, it was observed that the home¿s first aid kit did not include a first aid manual, in violation of § 6400.77(c).
This occurred due to a previously replaced kit being restocked without confirming the inclusion of the manual. The absence was not identified during routine checks.
Corrective Action Taken:
As of May 1, 2025, all homes were issued brand-new, fully stocked first aid kits, which include the required first aid manual.
The Facility Compliance Manager verified that the manuals were included and placed directly inside each kit to ensure accessibility in emergencies.
The kits were labeled and placed in designated, easily accessible areas of each home. |
05/02/2025
| Implemented |
| 6400.82(e) | On 4/30/2025 at 10:52AM, the bathtub, in the bathroom of the home, did not have a nonslip surface or mat. | Bathtubs and showers shall have a nonslip surface or mat. | How we plan to correct the non-compliance:
What happened / Why did it happen:
On April 30, 2025, during the inspection, it was observed that the bathtub in the home did not have a nonslip surface or mat, which poses a fall risk and violates § 6400.82(e). The oversight occurred because staff removed the previous mat during cleaning and failed to replace it. There was no system in place to verify that required safety items remained in place after routine housekeeping.
What specific change was made to fix the problem:
On May 1, 2025, a new nonslip bath mat was placed in the tub. The mat is securely installed and covers the base of the tub to prevent slips or falls during bathing.
Who made the change and when:
The Facility Compliance Manager placed the new nonslip mat on May 1, 2025, and verified its proper installation.
How was the issue corrected:
The mat was tested to ensure it remained securely in place. Staff were trained on the. 6400.82 (e) regulatory requirements and to ensure the mat is replaced for compliance after cleaning. |
05/01/2025
| Implemented |
| 6400.104 | The letter to the local fire department, dated 12/09/2024, did not include exact locations of the bedrooms of the individuals who need assistance evacuating in the event of an actual fire. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| How we plan to correct the non-compliance:
What happened / Why did it happen:
The letter to the local fire department, dated December 9, 2024, did not include the exact locations of the bedrooms for individuals requiring assistance during a fire evacuation. This omission occurred due to the use of an outdated letter template that did not contain all the required components outlined in § 6400.104. The document was submitted without verification against current regulatory standards.
What specific change was made to fix the problem:
On May 2, 2025, an updated fire department notification letter was created using a corrected template that includes:
The address of the home
The number of individuals in the home
Specific bedroom locations of any individuals who require assistance evacuating
Floor plan indicating bedroom and exit locations (if applicable)
A revised letter was sent to the local fire department and a signed confirmation of receipt was requested.
Who made the change and when:
The Program Specialist updated the letter and submitted the corrected version to the fire department on May 2, 2025.
How was the issue corrected:
The revised letter is now part of the individuals home file and the administrative emergency preparedness binder. Documentation includes the floor plan and confirmation of delivery. |
05/02/2025
| Implemented |
| 6400.166(a)(11) | Individual #1 is prescribed Valproic Acid 250mg/5ml, take 30ml by mouth at bedtime for Seizure disorder. Individual #1's April 2025 Medication Administration Record documented the purpose of Valproic Acid as Schizoaffective. | 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. | Provider¿s Plan of Correction
What Happened / Why It Happened:
During the review of Individual #1s April 2025 Medication Administration Record (MAR), it was noted that Valproic Acid 250mg/5ml, prescribed 30ml at bedtime for seizure disorder, was incorrectly documented on the MAR with the purpose listed as Schizoaffective disorder.
This error occurred during manual entry into the MAR system and was not verified against the prescribing instructions at the time of entry.
Corrective Action Taken:
The Program Specialist reviewed the prescribing order and confirmed the correct purpose is seizure disorder.
The MAR was immediately updated to reflect the correct prescribing instructions and medication purpose.
All current MAR entries for Individual #1 were reviewed for accuracy to ensure no other discrepancies exist. |
05/02/2025
| Implemented |
| 6400.166(b) | Atorvastatin 80mg tab, take 1 tablet by mouth every day at bedtime and Valproic Acid 250mg/5ml., take 30ml by mouth at bedtime, prescribed to Individual #1 was not initialed as administered at 9:00PM on 4/29/2025. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Providers Plan of Correction
What Happened / Why It Happened:
On April 29, 2025, at 9:00 PM, the MAR for Individual #1 did not contain staff initials for the administration of the following prescribed medications:
Atorvastatin 80mg 1 tablet at bedtime
Valproic Acid 250mg/5ml 30ml at bedtime
The medications were administered as prescribed, but not documented in the MAR due to a power outage in the home caused by a severe storm. The laptop was dead and the electronic MAR system (Therap) could not be accessed. The staff person completed their shift and left before power was restored, resulting in the documentation never being entered.
Corrective Action Taken:
The Program Specialist verified that the medications were administered and no doses were missed.
A documentation Error was recorded , and the staff member received a written warning for failing to follow up with documentation.
The staff person was retrained on medication administration protocols, including emergency backup procedures and documentation expectations.
Paper MARs have now been placed in the home to ensure staff have a backup documentation method during outages or electronic issues. |
05/23/2025
| Implemented |
| 6400.182(c) | Individual #1 is prescribed Trulicity 3mg with instructions to, "Inject 3mg subcutaneously every week." Individual #1's individual support plan, last updated 12/06/2024, states the individual was recently taken off of insulin. Individual #1's assessment completed 11/08/2024, states the individual has up to 4 hours of unsupervised time in the community. Individual #1's individual support plan, last updated 12/06/2024, states he requires 0 hours of supervision in the community and requires 24 hours of supervision at home. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Providers Plan of Correction
What Happened / Why It Happened:
During inspection, it was discovered that Individual #1 ISP, dated 12/06/2024, contained two inconsistencies:
It stated the individual was recently taken off insulin, while the current medication order includes Trulicity 3mg, a weekly injectable medication.
The assessment, dated 11/08/2024, states that the individual may be unsupervised in the community for up to 4 hours, but the ISP lists 0 hours of unsupervised time in the community and incorrectly states that 24-hour supervision is required at home.
These discrepancies occurred due to inadequate review of the assessment and medication orders prior to finalizing the ISP.
Corrective Action to Be Taken:
On May 22, 2025, the Program Specialist will submit a correction request to the Supports Coordinator to:
Update the ISP to reflect that Trulicity 3mg is currently prescribed.
Correct the supervision level to match the assessment: 4 hours unsupervised in the community.
Upon receipt of the corrected ISP, the Program Specialist will review the changes and all support staff will be reissued the updated plan for implementation and signature acknowledgment. |
05/22/2025
| Implemented |
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