| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.76(a) | The chair located by the filing cabinets in the kitchen area was visibly worn to the point that the chair material was completely worn through and the underlying chair foam was exposed in several areas. The chair was removed to the garage at the time of inspection, and the provider indicated it would be thrown away. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The chair was disposed of and replaced. |
02/16/2026
| Implemented |
| 6400.141(a) | Physical Examinations were completed with Individual #1 on 03/26/2024 and 09/15/2025, which exceeds the annual requirement. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | A tickler was set in our nursing calendar to remind our nurse to follow the correctly time lime established by ODP's policy. |
03/02/2026
| Implemented |
| 6400.141(c)(4) | The 09/15/2025 Physical Examination for Individual #1 does not address vision and hearing screenings. The section was left blank on the form with a written note "unable to complete". Additionally, the doctor's printed summary sheet does not list these areas in the assessment. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Our nurse addressed those findings with the individual's doctor and it has been established that he will he will address all required information on the next annual physical. |
03/01/2026
| Implemented |
| 6400.141(c)(10) | The 09/15/2025 Physical Examination for Individual #1 does not address whether the individual is free of communicable diseases. The section was left blank. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | Our nurse addressed those findings with the individual's doctor and it has been established that he will he will address all required information on the next annual physical. |
03/01/2026
| Implemented |
| 6400.141(c)(14) | The 09/15/2025 Physical Examination for Individual #1 does not address medical information pertinent to diagnosis and treatment in case of an emergency. The section was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Our nurse addressed those findings with the individual's doctor and it has been established that he will he will address all required information on the next annual physical. |
03/01/2026
| Implemented |
| 6400.143(a) | Individual #1 is under the care of a Neurologist. There is documentation on record of a 10/06/2025 appointment; however, the form contains only individual's DOB, appointment date and time, reason for visit, Neurologist name, and phone number. All other sections of the form are incomplete, including findings, diagnosis, assessment, recommendations, and medication changes (if applicable). No other documentation was available for review for the licensing review period. Per the provider, the individual refuses treatment; however, documentation of refusal and continued attempts to train the individual about the need for health care were not found in the individual's record. | 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. | A team meeting was held with the individual's support team to discuss appointment visit refusals. It was agreed that our nurse will adequately document occurrences of refusals and file them accordingly. The individual was trained on the importance of complying with medication visits and the disadvantages of not complying. |
03/04/2026
| Implemented |
| 6400.216(a) | Records containing personal and protected information were found stored in an unlocked cabinet in the kitchen. This was corrected at the time of the visit, and files were relocated to a locked cabinet in the same area. | An individual's records shall be kept locked when unattended.
| All record in the individuals home were moved to the locked area of the home. |
03/01/2026
| Implemented |
| 6400.32(r) | The door to Individual #1's bedroom was not equipped with a lock and documentation was not provided to show the right was waved. | An individual has the right to lock the individual's bedroom door. | A lock was install on the bedroom door. |
03/02/2026
| Implemented |
| 6400.165(g) | Individual #1's is prescribed medications to treat psychiatric illness, which requires review every 3 months. The first review on record for the licensing period was completed on 07/09/2025. No other records were available for review prior to this date. | 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. | Often, this individual's review are done by tele visit. Unfortunately, it has been a challenge getting post visit summary from the physician. We have had a meeting with this doctor to discuss the violation pointed out in section. The doctor promised to be more forthcoming with emailing and faxing the necessary paperwork immediately after each visit. |
03/01/2026
| Implemented |