| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(e)(1) | Per Individual #2's financial record, the individual used gift cards to make purchases on 05/22/2025. A Weis Gift card was used to make a purchase at Weis grocery store and a Giant gift card was used to make a purchase at a Giant grocery store on this date. There was no record related to the origin of these gift cards, such as the individual choosing to purchase them for themselves. Further, the gifting of these gift cards to the individual would have constituted a deposit for the individual at the time of occurrence. In either case, the provider failed to keep a complete financial record of the purchase or deposit, whichever it might have been. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. | Staff will receive retraining on maintianing the financial logs. |
10/31/2025
| Implemented |
| 6400.22(e)(3) | Individual #2's financial record contained a receipt for an ATM withdrawal that occurred on 06/04/2025 in the amount of $60.00. Staff noted on accompanying documentation that these funds were utilized to pay for a haircut; however, the financial record did not contain documentation of the haircut occurring, an expense that reportedly exceeded $15.00 per the documentation accompanying the ATM withdrawal. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | Staff will receive retraining on maintianing the financial logs. |
10/31/2025
| Implemented |
| 6400.82(f) | At the time of inspection, the home's bathroom was lacking soap and a trashcan. Both were located within the home and placed in the bathroom by the provider prior to the conclusion of the on-site inspection. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Expectations for supply needs will be reviewed with staff. |
09/30/2025
| Implemented |
| 6400.141(c)(4) | Per the Individual Record, Individual #2's two most recent vision examinations occurred on 04/16/2024 and 05/31/2025---more than 365 calendar days apart. This individual did not receive vision examinations annually as required. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | A case manager was hired on 3/3/25 to replace the previous client services director who left in July of 2024. |
10/31/2025
| Implemented |
| 6400.142(a) | Per Individual #2's Individual Record, Individual #2's most recent dental examination took place on 10/31/2023. Records indicated that the individual refused to attend dental examinations on 05/05/2025, 06/26/2025, and 06/27/2025. There was no record that the provider attempted to secure dental care for this individual between 10/31/2023 and 05/05/2025. This individual did not receive a dental examination annually as required. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Another dental appointment was scheduled for Individual #2. |
10/31/2025
| Implemented |
| 6400.143(a) | Per Individual #2's Individual Record, Individual #2's most recent dental examination took place on 10/31/2023. Records indicated that the individual refused to attend dental examinations on 05/05/2025, 06/26/2025, and 06/27/2025. There was documentation of the refusal of treatment on 05/05/2025. While documentation of refusal of treatment was present for the 06/26/2025 and 06/27/2025 appointment attempts, neither form noted that training on the importance of healthcare was completed with the individual. The section of the 06/26/2025 form designed for this information was left blank. The 06/27/2025 form noted "Staff would need to work with [Individual #2]···" in order to educate the individual; however, the specific phrasing of this documentation suggested that the training did not actually occur. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | New case manager was given education on how to complete the forms for missed appointments. |
09/30/2025
| Implemented |
| 6400.165(g) | Individual #2 is prescribed psychotropic medication to treat the symptoms of a psychiatric illness. Per the Individual Record, this individual saw a psychiatrist for management of these medications on 08/13/2024, 10/11/2024, 12/13/2024, 02/11/2025, and 04/09/2025. Per documentation, the individual's 06/10/2025 psychotropic medication review was canceled due to "unsafe behaviors," and there is no other record of a visit more recent than 04/09/2025. The documentation did not classify this as a refusal of treatment. This individual did not have a psychotropic medication review conducted at least once every 3 months as required. | 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. | Another psychiatric appointment was already completed in August for this individual. |
09/30/2025
| Implemented |
| 6400.181(f) | Per Individual #2's most recent Individual Support Plan (ISP), dated 07/30/2025 in the Home and Community Based Information System (HCSIS), this individual's most recent Individual Plan meeting took place on 04/24/2025. The most recent Annual Assessment for this individual was dated 04/09/2025, less than 30 calendar days prior to the Individual Plan meeting. An email provided as record of the transmission of the ISP to the Individual Plan team was dated 07/15/2025. The documentation showed that the ISP was not provided to Individual Plan team members at least 30 calendar days prior to the Individual Plan meeting as required. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Newly hired Case Manager was given education in completion and time frames for Annual assessments |
10/31/2025
| Implemented |