| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(d) | The fire drills did not document the duration of the evacuation | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | The fire drill log has the evacuation start time and end time. |
02/02/2026
| Implemented |
| 6400.144 | The following medications were missing from the medication box of individual #1: Daily Medications: - Calciportien .005% - Estradiol .01% - Clobeta Sol .05% - Triamcinolone .1%
PRN medications: - Xhance 93mcg - Ventolin HFA Inhaler - Halls Cough Drops - Triamcinolone .1% - Diclofenac 1% - Clindamycin 1% | 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.
| Daily medication refills were on back order and delivered to the individual home within 48hours by the mobile pharmacy. |
02/02/2026
| Implemented |
| 6400.163(a) | Individual #1 is prescribed Veozah 45mg Tab to be taken at 8:00am. This medication was present in the medication box; however it did not have a pharmacy label attached. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | The house manager, med certified dsp and nurse will ensure each medication has its original labeled containers issued by the pharmacy. |
02/02/2026
| Implemented |
| 6400.166(b) | The following medications prescribed to individual #1were missing signatures on her January 2026 MAR: Missing signatures: - Amitriptyline -- 10mg - Veozah -- 45mg - Rosuvastatin -- 40mg - Propranolol -- 20mg The remainder of the individuals medications were not documented at all when the individual was in the hospital, however the absence due to the hospitalization should be documented on the MAR. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The individual was hospitalized during the dates unsigned on the MARS. |
02/02/2026
| Implemented |