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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.77(b) | There was no thermometer in the home at the time of inspections | 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. | Thermometer has been added to the first aid kit |
04/01/2026
| Implemented |
| 6400.144 | Individual 1's medication blister packs 8am on April 1st were still present at site, unpunched at the time of inspection. It was reported that the medications were administered this morning, however if the medications are being administered from somewhere other than the date outlined on the blister pack there should be documentation of such. Clonazepam 1MG Prescribed to individual 1 had inconsistent administration directions. The MAR says to take as needed for agitation, however the blister pack has it listed as twice a day, 8am and 8pm. Individual 1 is prescribed Naltrexone 50MG -- 1 tablet by mouth at 8am and 8pm -- This medication is listed on the MAR however the medication is not present 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.
| To ensure that the medication is being administered from one blister pack. Individual was just seen by their psych doctor 4/16/2026, who said that they will straighten out the medication order once the blood work is received and will see individual again on 4/23/26. |
04/16/2026
| Implemented |
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