| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Individual #4's Individual Support Plan (ISP) states that Individual #4 does not know how to identify poisonous substances. All substances are kept in a certain area of the home, and he is never left unsupervised around cleaning products. At the time of the inspection, the Panrosa Pink Cotton hand soap located in main bathroom label stated to seek medical attention or call poison control if ingested. Once the Licensing Representative pointed out the label to the agency staff, they thew the soap away during the inspection. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The soap was disposed of in the trash at the time of the inspection. Effective 7/15/2025, all residential services locations were provided with Softsoap brand, non-toxic soap. |
09/01/2025
| Implemented |
| 6400.112(h) | The fire drill conducted on 3/6/25 at 1pm did not indicate if everyone arrived at the meeting place as the section was left blank on the form. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | The house supervisor was re-trained on conducting monthling fire drill form. |
09/01/2025
| Implemented |
| 6400.141(a) | Individual #4 had a physical examination completed on 4/30/24 and their next examination occurred on 7/11/25. This exceeds the requirement. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | A spreadsheet/tracker will be created to verify all important dates surrounding Individual Health, including annual physicals and TB testing. |
09/01/2025
| Implemented |
| 6400.141(c)(3) | Individual #4 had a physical examination completed 7/11/25 and their last Diptheria/Tetanus was noted on the form as being done 9/21/1983. The Centers for Disease Control (CDC) recommends that the Tetanus and Diphtheria be given every 10 years. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Effective7/28/2025, Individual #4 received a Diphtheria/Tetanus booster has been schedule that will occur7/31/2025. |
09/01/2025
| Implemented |
| 6400.141(c)(14) | Individual #4's physical examination dated 7/11/25 did not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | An addendum form for the annual physical, was created to specifically address pertinent information to diagnosis and treatment in case of an emergency. Prior to 09/01/2025, the addendum form will be completed for Individual #4 by their Primary Care Physician to add to current annual physical in the file. |
09/01/2025
| Implemented |
| 6400.141(c)(15) | The annual physical shall include instructions for the individual's diet. Individual #4 had a physical examination completed on 7/11/25 and the area of nutrition/diet on the physical exam form was left blank. | The physical examination shall include:Special instructions for the individual's diet. | An addendum form for the annual physical, was created to specifically address the area of nutrition/diet. Prior to 09/01/2025, the addendum form will be completed for Individual #4 by their Primary Care Physician to add to current annual physical in the file. |
09/01/2025
| Implemented |
| 6400.143(a) | On 2/3/25, Individual #4 had a vison appointment and the form noted "unable to assess ocular pt uncooperative examination under sedation. Individual #4 had an ophthalmology appointment on 4/22/25 and the form notes "unable to perform exam-referring to specialist for sedation exam. There is no record or documentation that Individual #4 was trained on the importance of routine eye/medical care. On 3/25/25, Individual #4 had an ultrasound and the form noted "unable to perform test patient combative and not able to perform command." There is no record or documentation that Individual #4 was trained on the importance of routine medical care. Individual #4 had a dental consultation on 4/1/25, and the form had the" yes box checked that was the examination, procedure, or treatment refused." There is no record or documentation that Individual #4 was trained on the importance of dental treatments. Individual #4 had a physical examination on 7/11/25 and the exam form noted "unable to assess" for Individual's vision and hearing screening as well as systems assessment of eyes, ears, nose & throat, and neck/lymph nodes. There was no record or documentation of attempts to educate or train Individual #4 on routine medical care. On 7/14/25, Individual had a rehabilitation services lymphedema therapy, and the form had the "yes box checked that was the examination, procedure, or treatment refused." There is no record or documentation that Individual #4 was trained on the importance of routine medical care. | 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. | Effective 7/31/2025, a de-sensitization plan was created. All house staff members were trained on the de-sensitization plan and proper reporting of refusals effective 8/18/25. |
09/01/2025
| Implemented |
| 6400.144 | On 6/24/24 Individual #4 had a Primary Care Physician (PCP) visit and the after-visit summary and agency medical report form noted a referral to Psychiatry. There is no record or documentation that Individual #4 has been seen by a psychiatrist. | 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.
| Prior to 9/01/2025, agency will work with Individual #4¿s PCP to locate a psychiatrist and/or to amend past recommendations due to lack of current necessity. |
09/01/2025
| Implemented |
| 6400.211(b)(3) | Individual #4's record did not include the name, address, and telephone number of the person able to give consent for emergency medical treatment. | Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.
| Effective 7/16/2025, Individual #4¿s record was updated to include the admission date. |
09/01/2025
| Implemented |
| 6400.165(b) | A prescription order shall be kept current. According to Individual #4's 7/11/25 after visit summary form from Physicians Practice provided by the agency to the Licensing Representative on 7/16/25 via email it noted that Individual #4's fluticasone Propionate 50 mcg nasal spray order was changed to 2 sprays into each nostril every 12 (twelve) hours as needed for rhinitis. At the time of the inspection on 7/15/25, Individual #4 Medication Administration Record (MAR) and the medication in the home with the pharmacy label noted Fluticasone Prop 50 mcg, spray 2 sprays inro each nostril every day. According to the Regulatory Compliance Guide (RCG) "Kept current" means adhering to the most recent prescription for a medication. | A prescription order shall be kept current. | Effective 7/19/2025, the fluticasone prop medication with new pharmacy label were placed in the home and the individual¿s Medication Administration Record (MAR) was updated accordingly. |
09/01/2025
| Implemented |
| 6400.165(c) | Individual #4 is prescribed Fluticasone Prop 50 mcg, spray 2 sprays inro each nostril every day. The pharmacy label on the medication had a date filled of 10/19/24, and approximately ¼ of the medication remained in the bottle at the time of the inspection. The box of the medication stated it contained 120 metered sprays. The medication is not being administered as prescribed as a new medication would have been need approximately by December 18, 2024. The medication is not being administered as prescribed. | A prescription medication shall be administered as prescribed. | Effective 7/11/2025, staff reported issues with Individual #4 refusing to take Fluticasone Prop 50 mcg nasal spray on a frequent/regular basis. As a result, Individual #4¿s PCP changed the order to as needed. |
09/01/2025
| Implemented |
| 6400.213(1)(i) | Individual #4's record did not include their date of admission as this section of the form was left blank. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Effective 7/16/2025, Individual #4¿s record was updated to include the admission date. |
09/01/2025
| Implemented |