| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The drip pan on the stovetop was visibly dirty, and the door jamb to the sliding door was found dirty along the floor rail. | Clean and sanitary conditions shall be maintained in the home. | WHO (Responsible Party):
The House Manager is responsible for correcting and overseeing this issue.
WHAT (Noncompliance Identified):
The stovetop drip pan was visibly dirty, and the door jamb and floor rail of the sliding door were found to be dirty, resulting in the home not being maintained in clean and sanitary condition.
WHEN & HOW (Corrective Actions):
Immediately upon identification, the stovetop drip pan was removed and thoroughly cleaned to eliminate all visible dirt and residue. The sliding door jamb and floor rail were cleaned to restore clean and sanitary conditions. The Program Specialist inspected the kitchen and surrounding areas to ensure all identified concerns were fully corrected.
A review of all kitchen appliances and high-touch areas was conducted to determine whether any additional sanitation issues were present.
No additional deficiencies were identified. |
12/18/2025
| Implemented |
| 6400.141(a) | Individual #1's last annual physical examination took place on 11/06/24. To date, another physical has not been completed and is now past the maximum allowable timeframe for annual completion. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | WHO (Responsible Party):
The House Manager, Program Specialist and Agency Nurse are is responsible for correcting and overseeing this issue.
WHAT (Noncompliance Identified):
Individual #1's annual physical examination was not completed within the required 12-month timeframe. The last physical occurred on 11/06/2024, and a subsequent annual physical had not been completed at the time of review.
WHEN & HOW (Corrective Actions):
Immediately upon identification, the provider scheduled Individual #1 for an updated annual physical examination to bring the record into compliance with ODP requirements. The appointment was completed on 01/02/2026. (Attachment 2). The Program Specialist and House Manager reviewed the individual's medical file to ensure no immediate health or safety concerns were present during the lapse. Documentation of the completed physical was obtained and placed in the individual's record upon completion.
No additional deficiencies were identified. |
01/02/2026
| Implemented |
| 6400.144 | Individual #1 is prescribed Glucagen 1mg. The medication was listed on the MAR; however, was not available in the home. | 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 House Manager responsible for correcting and overseeing this issue.
WHAT (Noncompliance Identified):
Individual #1 was prescribed PRN Glucagon 1 mg, which was listed on the MAR but was not available in the home.
WHEN & HOW (Corrective Actions):
Upon identification, the provider reviewed the individual's medication orders with the Primary Care Physician (PCP). The PCP discontinued the PRN Glucagon 1 mg on 01/02/2026. The PCP stated that since the individual is not on insulin, and has not had a clinical need for this medication in over one year, he does not require it.
The MAR was immediately updated, and Glucagon was removed from the MAR to accurately reflect the current medication regimen. (See attachment). Documentation of the medication discontinuation was obtained and placed in the individual's medical record.
A review of the individual's remaining medication orders and MAR was conducted to ensure accuracy and completeness.
No additional deficiencies were identified. |
01/02/2026
| Implemented |