| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | Individual#1'a funds are not being used for her individual's benefit. On 10/2/25, at Weis Individual #1 purchased 12 Xlarge eggs for $3.49, and a Gallon of 2% milk for $4.49. On 8/8/25, at Walmart Individual #1 purchased Eggo Waffles for $2.87, and milk for $4.88. On 7/31/25, Individual #1 purchased onions for $2.99, 12 large eggs for $3.69 and a quart of 2% milk for $1.49 at Weis. On 2/5/25 at Weis Individual #1 purchased a half gallon of 2% milk for $2.49. These items should not be purchased using individuals' funds as they would be included in Room and Board. | Individual funds and property shall be used for the individual's benefit. | Staff retrained on how to guide individual during shopping. Site supervisor will check daily to ensure individual is not purchasing items that should be included in room and board with her funds. |
11/17/2025
| Implemented |
| 6400.64(a) | Clean and sanitary conditions shall be maintained in the home. At the time of inspection, located in the kitchen cabinet above the stove was an 8 oz. container of Reggiano grated parmesan & Romano cheese with the "best if used by 10/12/2025" on it, a container of Royco Machus spicy beef flavor with a with the "best if used by 9/25" on it. The ceiling vent located over the toilet in the bathroom had a significant layer of dust on it. | Clean and sanitary conditions shall be maintained in the home. | The 8 oz. container of Reggiano grated parmesan & Romano cheese is now thrown out. The bathroom ceiling vent is now cleaned with no dust on it. |
11/18/2025
| Implemented |
| 6400.141(c)(7) | On 11/4/24 Individual #1 went for a gynecological examination and the agency OBGYN appointment form noted under the summary of visit section on the form "pelvic exam limited by pt pain." The progress notes from the visit also noted exam limited by body habitus and pain. Patient exclaimed in pain with any internal exam, exam stopped. Unable to collect pap/do exam today d/t patient pain may need to consider OR for adequate pap collection next year. Individual #1 had a gynecological examination on 11/12/25, and the agency OBGYN appointment form noted patient unable to tolerate internal speculum exam/pap smear. The progress notes from the visit noted able to complete internal exam/pap smear. Individual #1 did not have a gynecological examination in 2025. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Program director reached out to the OBGYN office, a new plan of care has been established. And the individual is scheduled for OR consultation with the OBGYN doctor on January 13th, 2026 to determine moving forward if the individual will need to be under anesthesia during the exam. |
11/19/2025
| Implemented |
| 6400.142(a) | Individual #1 had a dental examination on 4/11/24 and their next one occurred on 7/29/25. This exceeds the requirement. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Program director reached out to the dentist office and the individual is scheduled for dental cleaning via anesthesia/OR consultation on 12/11/25. |
11/13/2025
| Implemented |
| 6400.142(d) | Individual #1 had a dental examination on 7/29/25, however the dental examination did not include or indicate if a cleaning occurred. | The dental examination shall include teeth cleaning or checking gums and dentures. | Program director reached out to the dentist office and the individual is scheduled for dental cleaning via anesthesia/OR consultation on 12/11/25. |
11/13/2025
| Implemented |
| 6400.142(e) | Individual #1 had a dental examination on 7/29/25. The dental examination form noted under the recommendation for dental care/ follow up extraction of left wisdom tooth (16) fillings on 9,10,11,12,20,18,19. There is no record or documentation that this has occurred or been scheduled for Individual #1 as of the inspection date 11/12/25. | Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed. | Program director reached out to the dentist office and the individual is scheduled for dental cleaning via anesthesia/OR consultation on 12/11/25. |
11/13/2025
| Implemented |
| 6400.142(e) | Individual #1 had a dental examination on 7/29/25. The dental examination form noted under the recommendation for dental care/ follow up extraction of left wisdom tooth (16) fillings on 9,10,11,12,20,18,19. There is no record or documentation that this has occurred or been scheduled for Individual #1 as of the inspection date 11/12/25. | Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed. | Program director reached out to the dentist office and the individual is scheduled for dental cleaning via anesthesia/OR consultation on 12/11/25. |
11/13/2025
| Implemented |
| 6400.143(a) | Individual had an Individual #1 had a gynecological examination on 11/12/25, the progress notes from the visit noted patient verbally consented to attempting vaginal exam. Upon attempted insertion of speculum, the patient began screaming "stop." Exam was immediately discontinued. There is no record or documentation of the agency training Individual #1 on the importance of annual gynecological 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. | Program director counseled/trained the individual on the importance in completing her OBGYN exam annually. |
11/17/2025
| Implemented |
| 6400.143(a) | Individual had an Individual #1 had a gynecological examination on 11/12/25, the progress notes from the visit noted patient verbally consented to attempting vaginal exam. Upon attempted insertion of speculum, the patient began screaming "stop." Exam was immediately discontinued. There is no record or documentation of the agency training Individual #1 on the importance of annual gynecological 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. | Program director counseled/trained the individual on the importance in completing her OBGYN exam annually. |
11/17/2025
| Implemented |
| 6400.144 | Individual #1 had a physical examination on 3/12/25 and the physical exam form noted low calorie diet. During the inspection on 11/12/15, the Licensing Representative inquired if Individual #1 had any dietary needs or restrictions and the agency staff reported that Individual #1 did not have any. Upon reviewing Individual #1's financial records they get take out frequently from Popeye's and following items: spicy thighs, classic thigh, classic leg, classic wing, coke, Cajun fries, and mac & cheese. The agency orders the is not following the doctors recommended low calorie diet for Individual #1. Individual #1 had a gynecological examination on 11/4/ 2024, and the progress note from the appointment notes that may need to consider OR (operating room) for adequate pap collection next year, and there is no record or documentation that the agency followed up on this recommendation for Individual #1's 2025 pap collection in 2025 as Individual #1 was seen at the ONGYN's office for their annual pap on 11/12/25, and it was unsuccessful. | 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.
| Immediately the agency started following the doctors recommendation of a low calorie diet. Her assessment has been corrected. The Program director reached out to the OBGYN office. A new plan of care has been established. And the individual has been scheduled for OR consultation with the OBGYN doctor on 1/13/26. |
11/17/2025
| Implemented |
| 6400.181(e)(3)(i) | Individual #1 had a physical examination on 3/12/25 and the physical exam form noted low calorie diet under the recommended diet and special instructions for the individual's diet section on the form. However, Individual #1's assessment 5/23/25 under the health section for individual #1's progress over the last 365 calendar days and current level did not address the low calorie diet recommendation from physical examination on 3/12/25. | The assessment must include the following information: The individual's current level of performance and progress in the following areas: Acquisition of functional skills. | The assessment is now corrected reflecting low calorie diet. Staff retrained on low calorie diet. |
11/17/2025
| Implemented |
| 6400.181(e)(13)(vii) | 181(e)(13)vii: Individual #1's assessment dated 5/23/25 states under Function skills/money management section that that Individual #1 is not able to purchase an item independently, Individual #1 can identify the items she desires to purchase, but can't make purchases without staff assistance, and that Individual #1 is not able to count money of any amount. At the time of the inspection, agency staff stated to the Licensing Representative that Individual #1 holds on to their debit card at all times. The agency did not assess Individual #1 appropriately in their financial management/independence. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| Individual's money management skills were discussed with her SC during her ISP meeting on 11/24/25 it was determined that individual should hold her debit card at all times to avoid behaviors at the store and staff should collect the receipt immediately after purchase. |
11/24/2025
| Implemented |