| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.143(a) | Individual #1 had a dental examination on 3/19/2026. The dental examination form indicated that Individual #1 had "B.W. X-Rays" performed during this examination. Staff reported that Individual #1 walked out of the appointment and that a cleaning was not performed. Recommendations for dental care plan/follow-up states that "patient needs cleaning". There is neither documentation of the dental exam refusal nor is there documentation of continued attempts to train the individual about the need for health care in the individual's record. | 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 is now trained on the importance of health care examination. see attached counsel /training document emailed to Kristen. |
08/26/2026
| Implemented |
| 6400.46(d) | Previous certificate for first-aid/CPR training on file for Staff Person #1 expired on 2/10/2026 and was not renewed until 5/7/2026. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | The staff was retrained on the importance of his CPR being current and renewed in a timely manner. see attached copy of Memo/counseling given to staff emailed to Kristen |
08/17/2026
| Implemented |
| 6400.165(c) | Individual #1 is prescribed Metamucil Powder, mix 1 teaspoon in 8oz of liquid and drink by mouth once daily at 8AM. Medication Administration Record (MAR) for this medication for August 2026 was blank and did not reflect that Metamucil Powder was administered on August 1, 2, 3, or 4, 2026. Medication is not being administered as prescribed. | A prescription medication shall be administered as prescribed. | All staff were retrained on documentation of prescribed medication. See attached staff training sign-in sheet emailed to Kristen. |
08/05/2026
| Implemented |
| 6400.166(c) | Individual #1 is prescribed Metamucil Powder, mix 1 teaspoon in 8oz of liquid and drink by mouth once daily at 8AM. Staff reported that Individual #1 continues to refuse this medication. The Medication Administration Record (MAR) for August 2026. There is no documentation of the medication refusal or that the refusal was reported to the prescriber. | If an individual refuses to take a prescribed medication, the refusal shall be documented on the medication record. The refusal shall be reported to the prescriber as directed by the prescriber or if there is harm to the individual. | All staff were restrained. The refusal is now reported to the prescriber and the medication was discontinued. see attached staff training sign-in and d/c medication order from the doctor emailed to Kristen.. |
08/05/2026
| Implemented |