| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.214(b) | On 8/20/2025 at 12:45pm, the following information from Individual #1's record was not available on-site at the residential home: current physical examination completed 7/25/2025. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| A supervisor uploaded [Individual #1's physical to the electronic health record on 9/1/25. |
09/01/2025
| Implemented |
| 6400.162(a) | Chief Executive Officer #1's medication administration annual practicum that was recertified on 3/24/2025 did not include all course renewal requirements, therefore; Chief Executive Officer #1 was not qualified to provide medication administration for an individual who is unable to self-administer their prescribed medications. On 8/1/2025 Chief Executive Officer #1 administered the following medications to Individual #1 at 8:00pm: Aripiprazole 20mg tablet, Buspirone HCL 10mg tablet, and Buspirone HCL 15 mg tablet. | A home whose staff persons or others are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication. | The Compliance Officer ensured that only staff who have completed the medication administration "train the trainer" course are assigned to observe and certify medication practicums as of 8/28/25. |
08/28/2025
| Implemented |
| 6400.169(a) | Chief Executive Officer #1's medication administration annual practicum, which was recertified on 3/24/2025 by Certified Registered Nurse Practitioner #2, did not include all course renewal requirements as Certified Registered Nurse Practitioner #2 has not completed the Department's Medication Administration Train the Trainer Program. | 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). | As of 8/28/25, only DSPs who have completed all required practicum training under a qualified trainer will administer medications. |
08/28/2025
| Implemented |