| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | There was a soiled adult diaper on the floor of individual #2's bathroom. | Clean and sanitary conditions shall be maintained in the home. | The bathroom was cleaned, and the attendants were disposed of properly. All homes were inspected for clean and sanitary conditions. Additionally, staff were retrained on the expectations of maintaining a clean and hygienic environment. |
10/08/2025
| Implemented |
| 6400.64(b) | A dead insect was found in the hall closet at the time of inspection. | There may not be evidence of infestation of insects or rodents in the home. | The closet was cleaned and the insects removed 9/16/25. All sites are inspected to ensure pest control measures are adequate. No infestations found. Staff were retrained on the expectations of a clean and sanitary environment 9/17/25 |
10/08/2025
| Implemented |
| 6400.112(c) | The 10/22/2024 Fire Drill does not indicate that any individuals or staff participated in the drill. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | All fire drills for September were reviewed again for accuracy. Program staff were retrained on properly recording and documenting a fire drill. |
10/08/2025
| Implemented |
| 6400.113(a) | Individual #2 was admitted on 03/06/2025 and initial fire safety training was provided on 04/04/2025, which exceeds the allowable timeframe for training a newly admitted individual. | 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. | A file audit was completed, and Individual #2's initial fire safety training, conducted on 3/6/25, is part of the documentation submitted in the shared folder on the day of inspection. An additional drill on 9/4/25 was completed for annual fire safety and is also included in the shared file. |
10/08/2025
| Implemented |
| 6400.141(a) | Individual #2 was admitted on 03/06/2025, and a physical was completed on 05/06/2025. No other physical examinations were found on record. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Verified a complete physical examination for Individual #[2 on 5/6/25, completed, signed, and dated by a licensed provider. |
10/08/2025
| Implemented |
| 6400.216(a) | An individual support plan (ISP) containing medical and financial information for an individual was found unattended and unlocked. | An individual's records shall be kept locked when unattended.
| Individuals' records in the home were secured and locked (9/16/25).. An Audit was completed in all homes to ensure compliance and security of records (9/17/25) |
10/13/2025
| Implemented |
| 6400.166(b) | Individual #2 is prescribed Carvedilol at 8:00pm. The dose was administered from 09/12/25 to 09/15/25; however, the administrations were not logged and signed off on the MAR.
Individual #2 is prescribed Eliquis at 8:00 pm. The dose was administered from 09/12/25 to 09/15/25; however, the administrations were not logged and signed off 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. | MAR was reviewed, and the staff who failed to document were retrained |
10/08/2025
| Implemented |