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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | On 4/30/2025 at 3:06PM, the door to the basement contained a locking mechanism, however, the lock was not engaged. The following poisonous substances were unlocked and accessible in the basement of the home: 19oz Lysol disinfectant spray, 2 containers of Comet bleach powder, 2 24 ounce bottles of soft scrub, 1 9 ounce bottle of furniture spray, 121 fluid ounce bottle of Clorox performance bleach, 180 fluid ounce bottle container of Clorox cleaner + bleach, a 23 fluid ounce bottle of Windex window spray, a 12 ounce container of Power House Carpet Cleaner spray, a 24 ounce bottle of Easy-Off oven cleaner. | Poisonous materials shall be kept locked or made inaccessible to individuals. | What specific change will be made: A locked storage cabinet was purchased and installed in the home. All poisonous substances, including cleaning products, were immediately placed inside the locked cabinet to ensure they are inaccessible to individuals.
Who will make the change: The House Supervisor and Facility Compliance Manager completed the installation and relocation of the cleaning products.
When will the change be made: The correction was completed on May 1, 2025.
How will the change be made: All cleaning products were gathered, cataloged, and secured in the new cabinet. The key to the cabinet is held by designated staff only. |
05/01/2025
| Implemented |
| 6400.80(b) | On 4/30/2025 at 9:57AM, there was a paver stone protruding from the ground overlapping the flat paver stone walkway posing a tripping hazard. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | Providers Plan of Correction :
What Happened / Why It Happened:
On April 30, 2025, at 9:57 AM, a paver stone was found protruding from the ground and overlapping the flat paver stone walkway, creating a tripping hazard for individuals and staff.
This violation occurred due to natural ground shifting and root disruption over time, and the issue had not been identified or addressed during prior weekly inspections.
Corrective Action to Be Taken:
The Facility Compliance Manager has scheduled immediate repair of the pavers.
The walkway will be leveled and reset to eliminate the hazard and ensure the surface is flat, even, and safe.
Any surrounding root structures contributing to the issue will also be evaluated and addressed to prevent recurrence.
Responsible Party & Timeline:
The Facility Compliance Manager will oversee and complete the repair by June 6, 2025.
The area will be blocked off from use until repair is complete. |
06/06/2025
| Implemented |
| 6400.82(e) | On 4/30/2025 at 3:06PM, there was no nonslip surface or mat in the shower in the bathroom in the basement of the home. | Bathtubs and showers shall have a nonslip surface or mat. | What specific change will be made: A nonslip shower mat was placed in the basement bathroom shower to eliminate the fall hazard and meet regulatory requirements.
Who will make the change: The Facility Compliance Manager installed the nonslip mat and confirmed proper placement.
When will the change be made: The correction was completed on May 1, 2025.
How will the change be made: A textured nonslip mat was placed inside the shower, and photo documentation was completed and filed. |
05/01/2025
| Implemented |
| 6400.82(f) | On 4/30/2025 at 3:06PM, there was no trash receptacle in the bathroom in the basement of the home. | 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. | What specific change will be made: A trash receptacle was placed in the basement bathroom to ensure proper waste disposal and compliance with sanitation standards.
Who will make the change: The Facility Compliance Manager delivered and placed the trash receptacle in the bathroom.
When will the change be made: The correction was completed on May 1, 2025.
How will the change be made: A standard bathroom trash can with a lid was added and labeled for regular emptying during daily routines. |
05/01/2025
| Implemented |
| 6400.50(a) | Direct Service Worker #1, date of hire of 4/1/2025, has a record of orientation that did not include the training source and content. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | How we plan to correct the non-compliance:
What happened / Why did it happen:
Direct Service Worker #1, hired on 4/1/2025, completed all required orientation training through Relias Learning. The training was completed and documented in Relias, but the orientation file initially lacked the training source and content details. When the licensing inspector requested certificates on April 30, 2025 at the end of the day, we were to reconvene the next day and provide the documents. However, a storm caused a power outage the administrative office , preventing access to the desktop computer and printer. The documents could not be printed or retrieved during the inspection the next day due to the multi-day outage.
What specific change was made to fix the problem:
Once power was restored on May 5, 2025, the Relias transcript and training certificates were retrieved, printed, and added to the staff file. The orientation packet was updated to include:
Date of training
Source: Relias Learning
Description/content summary
Printed transcript and certificates
Who made the change and when:
The Program Specialist updated the staff file and ensured all required documents were in place on May 3, 2025.
How was the issue corrected:
All documentation was filed in the staffs central office binder. |
05/05/2025
| Implemented |
| 6400.163(h) | Individual #1's prescribed medication, Clindamycin 1% lotion with instructions to, "apply topically to acne as needed" had an expiration date of 7/2024. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | How we plan to correct the non-compliance:
What happened / Why did it happen:
During the inspection on April 30, 2025, a bottle of Clindamycin 1% lotion prescribed to Individual #1 was found to be expired, with a listed expiration date of July 2024. This occurred due to a lapse in the routine review of stored medications. Staff did not identify and remove the expired medication in a timely manner.
What specific change was made to fix the problem:
On May 1, 2025, the expired medication was removed and properly disposed of following agency protocol. A new prescription of Clindamycin 1% lotion was ordered from the pharmacy and was delivered and placed in the homes secured medication storage.
Who made the change and when:
The Program Specialist confirmed the removal of the expired medication, placed the reorder, and ensured that the new prescription was received and documented on May 1, 2025.
How was the issue corrected:
The medication administration record (MAR) was updated to reflect the newly dispensed medication. |
05/01/2025
| Implemented |
| 6400.167(a)(1) | Individual #1 is prescribed Atropine Sulfate 1% Solution with instructions to, "place 1 drop into both eyes 2 times a day for eye swelling." Individual #1's April 2025 electronic Medication Administration Record has this medication being logged as being missed on 4/21/25 at 9:21PM for the 8:00PM administration time and also on 4/22/25 as being missed at 8:45PM for the 8:00PM administration time. Individual #1 is prescribed Dorzolamide Timolol 2-0.5% with instructions to, "Place 1 drop into both eyes 2 times a day for glaucoma." The April 2025 electronic Medication Administration Record has this medication being logged as being missed on 4/24/25 at 8:56PM for 8:00PM administration. The April 2025 electronic Medication Administration Record has this medication being logged as being missed on 4/21/25 at 9:21PM for 8:00PM administration, 4/22/25 being logged as missed at 8:45PM for 8:00PM administration, 4/23/25 being logged as missed at 8:41PM for 8:00PM administration, 4/24/25 being logged as missed at 8:36PM for 8:00PM administration, 4/28/25 logged as missed at 9:33PM for 8:00PM administration, and 4/29/25 logged as missed at 8:54PM for 8:00PM administration. | Medication errors include the following: Failure to administer a medication. | What Happened / Why It Happened:
During a review of the April 2025 Medication Administration Record (MAR), it was found that Individual #1 missed multiple prescribed doses of:
Atropine Sulfate 1% (for eye swelling) on 4/21/25 and 4/22/25
Dorzolamide Timolol 2-0.5% (for glaucoma) on 4/21/25, 4/22/25, 4/23/25, 4/24/25, 4/28/25, and 4/29/25
These medications were scheduled to be administered twice daily at 8:00PM, but were not given within the prescribed time frame and were instead marked as missed.
This violation occurred due to staff failing to adhere to med pass schedules, inconsistent shift coverage, and lack of accountability for evening medication administration.
Corrective Action Taken:
The Program Specialist reviewed the MAR with the assigned staff and House Supervisor.
A Medication Error Report was completed for the missed administration.
All staff assigned to this home were retrained on proper med administration procedures, including timely documentation and what constitutes a medication error.
A written performance warning was issued to staff who failed to administer or report the missed doses.
Who Made the Change:
The Program Specialist and Program Manager implemented the correction and conducted retraining |
05/23/2025
| Implemented |
| 6400.182(c) | Individual #1's assessment completed on 8/11/2024 states that he needs physical prompts to have knowledge of heat sources and would be unable to sense or move away from heat sources. The health and safety section of Individual #1's individual plan that was last updated on 3/31/2025 reads, "He does not require supervision around heat sources if in a well-lit area". Individual #1's assessment completed on 8/11/2024 states that he is unable to temper water and requires physical prompts for supervision around bodies of water. The water safety section of Individual #1's individual plan that was last updated on 3/31/2025 reads, "He is capable of tempering his own water. Staff must remain within visual range when swimming in a pool. He requires more supervision when around larger bodies of water such as rivers, lakes, and oceans. Staff must be within arm's length of him when around natural bodies of water to avoid injury associated with tripping. Staff will verbally prompt him to avoid hazards. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | What Happened / Why It Happened:
During the inspection on April 30, 2025, it was identified that Individual #1s assessment dated August 11, 2024, indicated that the individual:
Requires physical prompts to identify and avoid heat sources
Is unable to temper water independently and requires supervision around water
However, the ISP dated March 31, 2025, inaccurately stated the individual:
Does not require supervision around heat sources if in a well-lit area
Can temper his own water
This discrepancy occurred because the ISP was not cross-checked with the most current assessment prior to implementation.
Corrective Action to Be Taken:
The Program Specialist will send a request to the Supports Coordinator on May 22, 2025 to revise the ISP to match the assessment.
The corrected ISP will reflect:
The need for physical prompts and supervision around heat sources
The need for assistance with tempering water and supervision near bodies of water
Once the revised ISP is received, it will be reviewed, distributed, and signed by staff for implementation. |
05/22/2025
| Implemented |
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