| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | The three windows that comprised the kitchen's bay window were unable to be locked. | Floors, walls, ceilings and other surfaces shall be in good repair. | The Work order was submitted to the maintenance department and repair is scheduled for 4/16/26. The Residential Supervisor will retrain staff to identify areas in the home needing maintenance/repairs and report the concerns to the Residential Supervisors. The Residential Supervisor will communicate with Manager of Facilities to submit work orders with the contractor for the agency in order to schedule and complete repairs needed. |
05/18/2026
| Implemented |
| 6400.151(c)(3) | The most recent physical completed on 2/3/25 doesn't indicate whether or not the staff person is free from communicable diseases. The doctor didn't check off free from communicable diseases or not, though the question was present on the form | 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. | The Human Resource Department will ensure that all staff physical exams are clearly documented to indicate if the staff are free from communicable disease or if that staff has a communicable disease but is able to work at the agency if specific precautions are taken that will prevent the spread of disease. The HR Dept will also ensure that the physical exams clearly indicate information on a medical problem which may interfere with the health of the clients. The staff physical that was cited for error was corrected by the Urgent Care facility to reflect that the staff was free from communicable diseases |
05/18/2026
| Implemented |
| 6400.171 | A foil pan containing prepared food was observed in the microwave oven. The food was removed during the inspection. | Food shall be protected from contamination while being stored, prepared, transported and served.
| Staff immediately removed the plate during the inspection. Staff will be retrained on the proper storage of food, and the importance of ensuring that food is appropriately stored/saved to protect the food from any form of contamination. |
05/18/2026
| Implemented |
| 6400.165(c) | Individual#1 medication administration record (MAR) and medicine label for Latanoprost SOL 0.005% read: "Instill 1 drop into right eye once every day at 9PM (Discard after 42 days, date opened: ___________). However, the label on the box showed that it was last filled on January 19, 2025. There was no other date on which to determine when the 42 days had been met | A prescription medication shall be administered as prescribed. | Medication that has instructions to be administered for a number of days, will have a start and end dates recorded to guide staff when to end administration of the prescribed medication. Staff will be trained in identifying start and end dates and following the instructions as prescribed on the labels and eMAR |
05/18/2026
| Implemented |
| 6400.166(a)(11) | Individual#1- medication administration records, both paper and electronic did not consistently include the diagnosis or purpose for the medications, instead it appeared to contain the name brand medication that the generic replaced. | 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. | The agency is actively working with the pharmacy to correct missing diagnoses in the MAR. The diagnosis and purpose for each medication, including PRN medications, will be added to the eMAR to ensure compliance. Staff will verify that this information is documented before administering medications, and ongoing monitoring will be conducted to maintain compliance. |
05/18/2026
| Implemented |