| 6400.143(a) | Individual #1 has had two (2) physical examinations since turning 40 years old, and a prostate examination has not been completed. The individual has a history of refusal and refused an exam during the 02/24/26 annual physical; however, there was no documentation on file of attempts to train the individual about the need for health care.
Individual #1 was seen by the PCP on 02/24/26 and 08/11/25. During those visits, a statin medication was recommended due to a "5.25% risk of 10-year adverse cardiac stroke." The individual continues to refuse treatment, and there was no documentation on file of attempts to train the individual about the need for health 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. | The individual record was reviewed and updated to ensure appropriate documentation of the refusal, including the date of refusal, service refused, staff response, education provided, and follow-up efforts. The Program Specialist reviewed documentation requirements with all direct support and supervisory staff |
08/06/2026
| Implemented |
| 6400.171 | An open jar of jelly that requires refrigeration after opening was found in the kitchen cabinet. The item was discarded during inspection. | Food shall be protected from contamination while being stored, prepared, transported and served.
| The opened jar of jelly was immediately removed and discarded. All food storage areas were inspected to identify and remove any additional opened or improperly stored food items .All direct support professionals and supervisory staff were retrained on food safety requirements, including proper food storage, labeling, expiration date monitoring, contamination prevention, and routine kitchen inspections. Training was documented in staff training records |
08/06/2026
| Implemented |