| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(a) | At the time of inspection, the small window located inside Individual #3's bedroom's walk-in closet was not equipped with a window screen. As there was no screen available in the home that could be fitted into this window, it was incapable of being securely screened. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | The window screen in Individual #3's bedroom walk-in closet was replaced immediately following the inspection to ensure the window is securely screened. |
04/17/2026
| Implemented |
| 6400.82(f) | This home's first-floor bathroom did not contain a wall mirror as required. | 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. | A wall mirror was installed in the home's first-floor bathroom immediately |
04/16/2026
| Implemented |
| 6400.112(h) | The fire drill forms for this location from 05/08/2025 through 03/02/2026 lacked the following information: whether the individual participating in the fire drill evacuated to a designated meeting place outside the building or within the fire safe area during each of the fire drills. There did not appear to be a space to record this information on the fire drill form that was used by the provider. The forms recorded the location of the home's designated meeting place but did not specify whether the individual reached it during the fire drills. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | The fire drill form was updated to include a section documenting whether individuals evacuated to the designated meeting place or fire safe area during each fire drill. Staff were informed of the updated documentation requirements. |
04/16/2026
| Implemented |
| 6400.113(a) | Individual #3 moved into this home on 03/02/2026. There was a record showing that this individual completed a fire safety training on the date that the individual moved into the home; however, as the training form did not include an address or other information that would identify the location associated with the fire safety training, it could not be confirmed that this fire safety training contained information specific to the home, e.g., designated meeting area, evacuation routes, location of smoke alarms, etc. Fire safety training must be site specific. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | The fire safety training form was updated to include the home address and site-specific fire safety information, including designated meeting area, evacuation routes, and smoke alarm locations. Individual #3's fire safety training was reviewed and documented accordingly. |
04/17/2026
| Implemented |
| 6400.144 | Per Individual #3's April 2026 Medication Administration Record (MAR), the individual was prescribed Pro Re Nata (PRN) Diazepam 5mg Tablet ("1 tab by mouth 2x dly as needed for anxiety/severe irritability must be 8 hrs apart"). According to the Chapter 6400 Regulatory Compliance Guide (RCG), revised 03/15/2023, the use of PRN psychotropic medications is only permissible if certain regulatory requirements are met. The requirements were not met for this medication in the two following areas:
1) The physician's prescription for the medication was lacking the specific symptoms that would necessitate the use of the medication. The prescribing physician would need to note, for example, that anxiety/severe irritation for an individual is expressed as "pacing back and forth while muttering to himself, throwing objects at staff, or slamming doors repeatedly" or other similar, observable symptoms of the diagnosis "anxiety/severe irritation." Alternatively to inclusion in the prescription itself, a protocol can be established outlining the specific symptoms so long as that protocol is reviewed and signed by the prescribing physician. Although the provider had such a protocol in place, the protocol was not reviewed and signed by the prescribing physician as required. The provider did not arrange these pharmacy services for the individual.
2) The provider's protocol for the administration of PRN psychotropic medications did not include the need for authorization by the CEO or CEO's designee for each instance of administration of a PRN psychotropic medication and that this authorization must be documented in the MAR. The PRN psychotropic medication protocol noted that, "Staff must notify the supervisor when PRN controlled medications are administered repeatedly," which did not meet this requirement. | 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.
| The provider updated the PRN psychotropic medication protocol to include required authorization and MAR documentation requirements for each administration. The clinical director reviewed and signed the PRN protocol containing observable symptoms requiring administration of the medication. Relevant staff were retrained on PRN psychotropic medication administration and documentation requirements. |
04/16/2026
| Implemented |
| 6400.165(g) | Individual #3 is diagnosed with a psychiatric illness and takes medications to treat associated symptoms. Per Individual #3's Individual Record, this individual attended psychiatric appointments on 05/23/2025, 08/15/2025, 11/05/2025, 01/14/2026, 01/22/2026, 01/29/2026, and 03/24/2026 to review the prescribed psychotropic medications. The documentation accompanying the 01/14/2026 appointment did not note the need to continue each medication reviewed, a required component of the documentation. | 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. | The psychiatric appointment documentation for 01/14/2026 was reviewed, and follow-up clarification was obtained to confirm continuation of the reviewed medications |
04/17/2026
| Implemented |
| 6400.67(c) | Per Individual #3's Individual Record, this individual has a documented history of ingesting paint chips, which has led to this individual contracting lead poisoning in the past. There was no documentation showing that the provider had the paint at this individual's residence tested for lead content as required. | If the home serves an individual 4 years of age or younger or an individual who ingests paint or paint substances, the home shall test all layers of paint at the home for lead content. If the testing shows lead content exceeding .06%, paint shall be completely stripped and recovered with lead free paint or securely encased with other lead free material. Documentation of the lead paint testing and results shall be kept. | The provider arranged for lead testing of painted surfaces within the residence following identification of the concern. Results and any recommended actions will be maintained in the individual's record. |
05/08/2026
| Implemented |