| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Clean and sanitary conditions are not maintained in the home. There was a black mold/mildew like substance located in the tub of the home under the faucet. There was standing water on the basement floor of the home. | Clean and sanitary conditions shall be maintained in the home. | Mold like substance was reported to CLA supervisor and cleaned.. |
01/13/2026
| Implemented |
| 6400.67(b) | The inside of the oven door contained a significant amount of grease, presenting a fire hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Oven was cleaned in order to reduce risk of fire. |
01/23/2026
| Implemented |
| 6400.72(c) | Outside doors to not have an operable lock. There are bilco doors to exit the basement of the home. These doors do not contain an operable lock. | Outside doors shall have operable locks. | Area of non-compliance reported to maintenance and repaired. |
01/16/2026
| Implemented |
| 6400.141(c)(9) | Individual #1 did not have a prostate exam or PSA testing completed annually. Individual #1 had a PSA test completed on 4/11/24 and has not had one completed since this date. | The physical examination shall include: A prostate examination for men 40 years of age or older. | Appointment was scheduled by CLA supervisor. Completed on 12/31. |
01/13/2026
| Implemented |
| 6400.144 | Health services including lab work are not planned for or arranged. Individual #1 had an appointment with the individual Primary Care Physician on 10/3/25, documentation from the appointment indicated that lab work was ordered and was to be completed the week of 10/6/25. There is no documentation that this lab work has been completed. | 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.
| Provider was able to verify that lab work was completed on 12/31. |
12/31/2025
| Implemented |
| 6400.216(a) | Individual records are not locked when unattended. There are multiple records including individual record information located in a pile in the basement. | An individual's records shall be kept locked when unattended.
| Heavy duty storage bins will be purchased for all CLAs. Historical records will be kept for 7 years and then be disposed of. |
01/16/2026
| Implemented |
| 6400.46(d) | Staff #3 was not trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques, and cardio-pulmonary resuscitation. Staff #3 was hired on 3/27/25 and was not trained in first aid, Heimlich, and cardio-pulmonary resuscitation until 12/20/25. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | CPR training was completed on 12/20 for Staff #3 |
01/13/2026
| Implemented |
| 6400.163(h) | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to applicable Federal and State statutes and regulations. Individual #1 is prescribed Bacitracin. This prescription expired on 9/3/24 and remained in Individual #1's medication box. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Discontinued/expired meds were located at all sites and disposed of. |
01/12/2026
| Implemented |
| 6400.165(c) | Medications are not administered as prescribed. Individual #1 is prescribed Flonase nasal spray, 1 spray into each nostril daily. The medication was filled on 9/11/25 and contains a 60-day supply. At the time of the inspection, 108 days after the medication was refilled, the bottle was more than half full. The medication would have needed to be refilled around mid-November if administered as prescribed.
Individual #1 is prescribed Pataday eye drops, instill one drop in each eye daily. This medication was filled on 11/19/25 and contained a 25-day supply. At the time of the inspection, 40 days after the medication was refilled, there was still medication remaining in the bottle. This medication would have needed to be refilled around mid-December if administered as prescribed. | A prescription medication shall be administered as prescribed. | All med trained staff at house retrained on proper med administration practices. |
01/16/2026
| Implemented |
| 6400.166(a)(11) | Individual #1 is prescribed Vit B-12, 1 tablet daily, Calcium, and Omeprazole. There is no diagnosis documented on the medication administration record (MAR) for these medications. Individual #1 is prescribed Loperaminde. The incorrect diagnosis for this medication is documented on the (MAR). The diagnosis for this medication is documented as constipation, however the instructions for administration indicate that the medication is to be administered for diarrhea. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Error was fixed on MAR on 1/7. |
01/16/2026
| Implemented |
| 6400.166(b) | Individual #1 is prescribed Loratadine. This medication is not documented on the medication administration record. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | MAR was updated. |
01/13/2026
| Implemented |
| 6400.186 | Individual #1's Individual Service Plan was not implemented. Individual #1's Individual Service Plan (ISP) states "Individual #1 needs to have staff present within eyesight at all times at the individual's home. Individual #1 needs staff present within arms reach at all times in the community." Individual #1 arrived home while an inspector was present at the home. Staff brought two individuals into the home. The licensing inspector was preparing to test the fire alarms when the individuals arrived home. Staff #2 who was accompanying the licensing inspector through the home asked for Staff #1's assistance with the fire alarms. Staff #1 set off the alarms and waited while the licensing inspector assessed their functionality and then proceeded to the basement to reset the system. Staff
#1 did not indicate that Individual #1 was still in the vehicle and did not proceed to bring Individual into the home until approximately 5 minutes after initially arriving at the home. The licensing inspector observed Staff #1 walking Individual #1 to the door as the licensing inspector was preparing to leave the home. Staff #1 then left the home to retrieve a recycling can from the street while Staff #2 was in the home. Staff #2 walked out of the home with the licensing inspector and quickly returned to the home upon observing Staff #1 to be outside of the home retrieving the recycling can. | The home shall implement the individual plan, including revisions. | Incident was investigated. Target retrained on supervision needs.
EIM #9758253 |
01/13/2026
| Implemented |