| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(e)(1) | On 1/30/2025 Individual #1 did not have a record of financial resources, including the dates and amounts of deposits and withdrawals. Individual #1's individual support plan, last updated 6/18/2024, states the individual needs others to budget and handle her money to ensure proper use. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. | 1. Immediate Creation of Financial Record: A financial record for Individual #1 is established. This record includes:
- Dates of all deposits and withdrawals.
- Amounts for each transaction.
- The purpose of each transaction.
2. Staff Training: A training session for relevant staff members is conducted on the importance of maintaining accurate financial records and the procedures for documenting all transactions. |
03/12/2025
| Not Implemented |
| 6400.62(a) | On 1/30/2025 at 10:33am there was a 1lb 2.8oz container of Radiance Disinfectant Wipes, with instructions to "Call a poison control center for treatment advice", located on a metal wire shelf, next to the kitchen. Individual #1's individual support plan, last updated 6/18/2024, states the individual "is aware of what items are unsafe to consume and would not likely ingest any toxic substance unless she was doing so in an attempt to get attention from someone." | Poisonous materials shall be kept locked or made inaccessible to individuals. | The 1lb 2.8oz container of Radiance Disinfectant Wipes was immediately removed from the metal wire shelf next to the kitchen and placed in a locked cabinet designated for storing all poisonous materials. The locked cabinet is located in an area inaccessible to individuals. Staff members were notified of this action and were reminded of the importance of ensuring that all poisonous materials are secured at all times. |
03/12/2025
| Not Implemented |
| 6400.65 | On 1/30/2025 in the on-suite bathroom with the first-floor bedroom, had a window with a black trash bag covering it from the inside. Direct Service Worker #1 stated the bag was to help keep the window insulated. There was no other source of ventilation. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| 1. Immediate Removal of Trash Bag: The black trash bag covering the window is removed to restore visibility and allow for natural ventilation.
2. Assessment of Ventilation Options: The current ventilation situation in the bathroom is evaluated to determine if the window can be opened for adequate airflow.
3. Inspection of Other Areas: A thorough inspection of all living areas, recreation areas, dining areas, individual bedrooms, kitchens, and bathrooms is conducted to ensure compliance with ventilation requirements. |
03/12/2025
| Not Implemented |
| 6400.72(b) | On 1/30/2025 the screen door, exiting to the back of the home from the basement, to the right of the garage, contained holes on the left side of the screen and was not attached to the bottom half of the door. | Screens, windows and doors shall be in good repair. | 1. Immediate Repair or Replacement: The existing screen door is repaired by patching the holes and reattaching the bottom half.
2. Inspection of Other Screens and Doors: A thorough inspection of all other screens, windows, and doors in the facility is conducted to identify any additional areas needing repair or maintenance.
3. Documentation of Repairs: The repair or replacement of the screen door is documented, including the date of completion and any materials used. |
03/12/2025
| Implemented |
| 6400.76(a) | On 1/30/2025 Individual #1's contained a 2-drawer end table, which was damaged and only contained one drawer. | Furniture and equipment shall be nonhazardous, clean and sturdy. | 1. Immediate Replacement: The damaged end table is removed and replaced with a sturdy, nonhazardous piece of furniture that meets safety and cleanliness standards.
2. Inspection of Existing Furniture: A thorough inspection of all furniture in Individual #1's room and other areas of the facility is conducted to identify any additional items that may be damaged or hazardous. |
03/12/2025
| Not Implemented |
| 6400.77(b) | On 1/30/2025 the first aid kit did not contain scissors and a thermometer. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | 1. Immediate Addition: A digital thermometer and scissors have been added to the first aid kit, ensuring compliance with required supplies.
2. Staff Retraining: All staff have undergone retraining on the updated first aid kit inspection procedure, including:
- Proper use of the digital thermometer and scissors
- Importance of maintaining a fully stocked first aid kit.
3. Daily Inspection Checklist: A daily checklist has been implemented for staff to verify the presence of all necessary first aid supplies.
4. Notification Protocol: A clear protocol for notifying supervisors if any item is removed from the first aid kit has been established. |
03/12/2025
| Implemented |
| 6400.81(i) | On 1/30/2025 the Individual #1's bedroom to the right of the bathroom, contained a window behind the bed, which did not contain drapes, curtains, shades, blinds or shutters. | Bedroom windows shall have drapes, curtains, shades, blinds or shutters. | To correct the non-compliance regarding the bedroom window in Individual #1's room, we installed drapes. Once installed, we verified that they cover the entire window and operate smoothly, ensuring adequate privacy and light control. Finally, we document the purchase and installation for compliance verification. |
03/12/2025
| Implemented |
| 6400.169(a) | Direct Service Worker #2 did not have an initial medication administration training completed due to having scored 80% on the initial examination portion. Direct Service Worker #2 administered medications to Individual #1 on 1/18/2025 at 8:00am. Direct Service Worker #3 did not have an initial medication administration training completed due to having scored 85% on the initial examination portion. Direct Service Worker #3 administered medications to Individual #1 on 1/21/2025 and 1/22/2025 at 8:00am and 12:00pm. Direct Service Worker #4 did not have an initial medication administration training completed due to having scored 87% on the initial examination portion. Direct Service Worker #4 administered medications to Individual #1 on 12/01/2024 at 8:00am. Direct Service Worker #5 did not have an initial medication administration training completed due to having scored 85% on the initial examination portion. Direct Service Worker #5 administered medications to Individual #1 on 12/07/2024 at 5:00pm. Direct Service Worker #6 did not have an initial medication administration training completed due to having scored 82% on the initial examination portion. Direct Service Worker #6 administered medications to Individual #1 on 12/09/2024, 12/16/2024, and 12/23/2024 at 8:00am. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | 1. Immediate Training for DSWs: Direct Service Workers #2, #3, #4, #5, and #6 complete the Department-approved medication administration training as soon as possible. This includes passing the examination portion with a score that meets the required threshold.
2. Review of Medication Administration Records: A thorough review of all medication administration records for Individual #1 is conducted to ensure that all administered medications are correctly documented and that no adverse effects occur due to untrained staff administering medications.
3. Supervision During Training: A qualified staff member is assigned to oversee the medication administration process until all involved DSWs successfully complete their training.
4. Documentation: Records of the training sessions, including attendance and examination results for each DSW, are maintained. |
03/12/2025
| Implemented |
| 6400.182(c) | Individual #'1's, date of admission 5/09/2023, individual support plan last updated 1/31/2025, does not document the individual's supervision needs in the residential setting. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | 1. Conduct a Needs Assessment: A thorough assessment of Individual #1¿s supervision requirements in the residential setting is performed. This includes input from direct service workers, family members, and the individual themselves.
2. Documentation of Changes: The updated ISP clearly documents any changes in supervision needs and the rationale behind those changes. However, the ISP has not yet been updated because the supports coordinator, who is the only one authorized to make these changes, has not responded to outreach efforts.
3. Review by Relevant Staff: The updated ISP is to be reviewed and approved by relevant supervisory staff to ensure compliance with regulations once changes are made.
4. Outreach to Supports Coordinator: The program specialist reached out to the supports coordinator on February 28th to update the ISP. The supports coordinator has not responded and has not made any changes to the ISP. |
03/12/2025
| Implemented |
| 6400.207(4)(I) | On 12/03/2024 Individual #1 was prescribed Diphenhydramine HCL 25mg as needed for mild or moderate agitation and Haloperidol 5mg as needed for severe agitation. On 1/302025 the individual did not have a protocol for the medications to include written instructions by a physician or medical practitioner listing the individual's specific symptoms of the psychiatric diagnosis that would warrant the use of a PRN psychotropic medication, nor authorization by the CEO or CEO's designee for each instance of administration of a PRN psychotropic medication. | A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition. | 1. Immediate Development of Protocol: Collaboration with the prescribing physician or a qualified medical practitioner occurs to create a detailed protocol for Diphenhydramine HCL and Haloperidol. This protocol includes:
- Written instructions specifying the individual¿s symptoms that warrant the use of each medication.
- Clear guidelines on when and how to administer these medications.
2. Obtain Authorization: Authorization from the CEO or the CEO's designee for the use of PRN psychotropic medications is secured, ensuring that this is documented for each instance of administration.
3. Review of Current Medications: A review of all current medications prescribed to Individual #1 is conducted to ensure protocols are in place for all PRN psychotropic medications. |
03/12/2025
| Not Implemented |
| 6400.213(1)(i) | 6400.213(1)ii On 1/30/2025 Individual #1' record documented her weight as 253lbs, last updated 10/07/23. Individual #1's prescription order for Ibuprofen 100mg/5ml Suspension documented her weight as 314lbs as of 1/15/2025. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | 1. Immediate Update of Weight Records: Individual #1's record is reviewed and updated to accurately reflect her current weight of 314 lbs as documented. All relevant sections of the record are updated accordingly.
2. Conduct a Comprehensive Review: A thorough review of all personal information and medical records for Individual #1 is performed to ensure consistency and accuracy across all documentation. |
03/19/2025
| Not Implemented |
| 6400.213(1)(i) | 6400.213(1)vi On 1/30/2025 Individual #1's record contained a photograph of the individual, last updated 3/11/2024. Individual #1's weight has drastically increased since this photograph was taken. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | 1. Immediate Update of Photograph: A new photograph of Individual #1 is scheduled to be taken as soon as possible. This new photograph accurately reflects her current appearance and is added to her record.
2. Documentation Review: A comprehensive review of Individual #1's personal information in her record is conducted to confirm that all required elements are present and accurately documented, including the photograph.
3. Record Entry: The new photograph is properly dated and documented in the individual's record, replacing the outdated photograph from 3/11/2024. |
03/12/2025
| Implemented |