| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | There were two containers of grout in the unlocked bottom cabinet of the 1st floor bathroom sink. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The Administrator removed the poisonous substance and secured it in a locked container to ensure safety and compliance. |
12/07/2025
| Implemented |
| 6400.62(d) | There was a poisonous cleaning product stored in a bottom kitchen cabinet with cooking oil. | Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces. | The poisonous substance was removed and secured it in a locked container to ensure safety and compliance. |
12/07/2025
| Implemented |
| 6400.68(c) | The home is connected to well water and there is no documentation of quarterly testing for coliform. | A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources¿ certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept. | Contact was made with the local Pump & Well Drilling company to set appointments for the next year to confirm that water is safe for drinking purposes. |
02/01/2026
| Implemented |
| 6400.76(c) | The chair in the bedroom of Individual #2 has a couple of large tears in it. | Furniture shall be comfortable and home-like. | The chair in Individual #2s room was replaced. |
02/01/2026
| Implemented |
| 6400.141(a) | Individual #2 most recent physical examination on file is dated 5/19/25, with possible evidence that a previous physical may have been completed in April of 2024 per documented PPD results. The last completed physical is dated 10/17/2023 which exceeds the annual requirement. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Biacon's nurse reviewed all physicals to ensure that they meet the annual requirement. |
12/15/2026
| Implemented |
| 6400.151(a) | Staff Member #4 had a physical examination completed on 3/28/22 and then on 5/9/24 exceeding the biennial requirement. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Employee files were audited to ensure physicals are valid and not due for completion. |
02/01/2026
| Implemented |
| 6400.151(c)(3) | The most recent physical examination of Staff Member #4 does not include if the person is free from communicable diseases. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | Staff member #4 obtained a newly completed physical dated 11/24/25 to verify that there are no communicable diseases present. |
11/30/2025
| Implemented |
| 6400.24 | Individual #2's medication Clonazepam for 8AM and 8PM did not have count sheets to keep track of the controlled substance. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | Narcotic count sheets have been provided to all homes with prescriptions for controlled substances. These count sheets have immediately been put to use. |
11/30/2025
| Implemented |
| 6400.46(b) | Staff Member #4 completed fire safety training on 1/26/24 and then on 4/9/25 and 4/25/25 which both exceeds the annual requirement. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | All employee files were reviewed to ensure that fire safety training has been completed for the current calendar year and meets the required annual requirement. |
11/30/2025
| Implemented |
| 6400.166(a)(11) | There was no diagnosis or reason for any of the medications (except for the PRNs) on the MAR of individual #2. | 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. | An updated MAR was completed for Individual #2 to include the diagnosis of each prescribed medication. |
12/01/2025
| Implemented |
| 6400.166(a)(13) | Staff person #4 administered Mounjaro injections per the MAR on 11/06/25 and 11/20/25 but did not have their name identifying their initials on the MAR of Individual #2. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | The Med Trainer conducted training and coaching with Staff Member #4 to reinforce the importance of completing the MAR accurately and legibly. |
12/18/2025
| Implemented |