| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | At the time of inspection, there was a small amount of feces located at the bottom of the toilet in the home's main bathroom. There were brown streaks on this area of the toilet bowl. This toilet was not in a clean and sanitary condition. | Clean and sanitary conditions shall be maintained in the home. | To reinforce best practices, QLHS will provide training to all staff on the importance of maintaining cleanliness and sanitary conditions throughout the home. This initiative supports the ongoing commitment to ensuring the health, safety, and well-being of both individuals served and team members. |
11/03/2025
| Implemented |
| 6400.64(f) | One of the trashcans in the home's backyard, which contained a bag of trash, was not covered with a lid. This allowed for penetration of the trash by insects or rodents. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | On September 3rd QLHS designated person placed the cover from the trashcans back on the can to prevent insects or rodents from getting into the trash. |
11/03/2025
| Implemented |
| 6400.67(a) | At the time of inspection, the two sliding closet doors corresponding to the closet in the staff office were taken off of their sliding tracks and leaning against the nearby wall. These closet doors could not be put back onto the tracks. | Floors, walls, ceilings and other surfaces shall be in good repair. | QLHS will have the maintenance team repair the two sliding closet doors located in the staff office to ensure they are in good working condition. This action is being taken to maintain a safe environment for staff and others who access the space. According to ODP regulations. |
11/03/2025
| Implemented |
| 6400.67(b) | The lower interior surface of the home's oven was speckled by small, black crumbs consistent with the charred remains of food. The interior of the oven's door was coated with brownish streaks consistent in appearance with grease or oil. The state of the home's oven increased the risk of a fire occurring in the home, constituting a hazard.
At the time of inspection, the lint trap of the dryer in the home's basement contained a golf-ball-sized accumulation of dryer lint. The presence of this lint in the dryer lint trap constituted a fire hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The QLHS Director has issued a memo placed on top of the dryer to remind staff to clean the dryer vent after each use. This measure is critical for fire prevention and for maintaining a safe and healthy environment for everyone in the home.
To reinforce this safety protocol, QLHS will retrain staff on the importance of cleaning the dryer vent after every usage. This practice helps ensure the home remains free of hazards and compliant with ODP regulations. |
11/03/2025
| Implemented |
| 6400.72(b) | The screen on the home's rear storm door was frayed along the edges, separating from the frame in several areas along its perimeter. In addition, the frame of the screen itself was bent such that it did not fit securely into the storm door.
The outer pane of one window in the home's basement-level garage was partially broken. A baseball-sized section of the outer pane was missing, allowing plants from the yard to grow into the area between the two windowpanes. A plant vine entered via the top of the window and grew several inches along the garage wall. | Screens, windows and doors shall be in good repair. | As of September 5, 2025, the QLHS Maintenance Team completed repairs to the rear storm door of the home, addressing an issue where the screen was separating from the frame.
To support ongoing home safety and upkeep, QLHS will retrain staff and supervisors on the importance of promptly reporting any concerns or issues within the home. Timely reporting ensures that all areas remain in good repair and compliant with safety standards. |
11/03/2025
| Implemented |
| 6400.82(e) | There was no bathmat located in the home's main bathroom, which contained a shower. | Bathtubs and showers shall have a nonslip surface or mat. | In alignment with ODP regulations, QLHS has purchased a bathmat for the main bathroom of the home to ensure safety and comfort for residents. Additionally, QLHS will conduct staff retraining focused on the importance of promptly reporting all household concerns and maintenance issues to supervisors and the maintenance team. This initiative aims to ensure that all repairs are addressed efficiently and in a timely manner. |
11/05/2025
| Implemented |
| 6400.82(f) | At the time of inspection, there were no individual clean paper or cloth towels found in either the staff bathroom or the main bathroom of the home. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | On September 3rd, clean paper towels were placed in the main bathroom of the home to ensure compliance with ODP hygiene standards. To reinforce regulatory adherence, all staff and supervisory personnel will receive training on the importance of maintaining fully stocked and properly equipped bathrooms. This training will emphasize the necessity of ensuring that all required items---such as paper towels, soap, and other hygiene supplies---are consistently available in accordance with ODP regulations. |
11/01/2025
| Implemented |
| 6400.101 | A deadbolt was installed on the door leading from the home's kitchen into the basement. The keyhole-side of the deadbolt was on the side of the door facing the basement. Staff on site could not locate the key to disengage this deadbolt from the basement side if it were to be locked from the kitchen side. If this deadbolt were engaged, it would constitute an obstruction to this means of egress during a fire or other emergency. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| QLHS will develop a comprehensive checklist for both staff and supervisors detailing all required items necessary to maintain compliance with ODP regulations within the home. This checklist will serve as a practical tool to ensure that essential supplies are consistently available and properly maintained. |
11/01/2025
| Implemented |
| 6400.144 | Per Individual #1's July 2025 Medication Administration Record (MAR), the individual was prescribed Cetirizine HCL 10mg tablet ("Take 1 tablet by mouth daily at 8am (allergies)") and Tab-A-Vite Tablet ("Take 1 tablet by mouth daily at 8am (supplement)"). Per the July 2025 MAR, both of these medications had the status "order pending provider review." On 07/11/2025, the MAR noted that Individual #1 was "physically unable to take" both of these medications. A 09/03/2025 phone discussion between this Licensing Representative and Newhard's Pharmacy facilitated by the provider agency revealed that these prescriptions were unable to be filled for the July fill date because they were out of refills and new prescriptions could not be obtained from the prescribing physician in time. Per documentation from the pharmacy, new prescriptions for these medications were not received from the prescribing physician until 07/24/2025. A delivery manifest shows that both medications were signed as delivered to Individual #1's home on 07/25/2025. Therefore, per documentation, these medications were unavailable to Individual #1 from 07/11/2025 through 07/24/2025.
The provider agency allowed prescription orders for these medications to lapse from 07/11/2025 through 07/24/2025. There was no evidence that the provider agency took alternative measures, such as securing new prescriptions from an alternative prescriber on an emergency basis, instead failing to secure the medications for Individual #1 between those dates. The provider agency did not secure pharmaceutical services for Individual #1 as required. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| The Pharmacy has requested refills for Individual #1 the medication could not be refilled until individual was seen by his physician. Individual #1 was seen and given new script for his medication. the medication was received, and the individual is currently taking the medication as prescribed. Team leads and Administrator was retrained on recognizing and reporting incidents. Cheat sheets were posted in every house for staff to refer to when they have questions. |
11/01/2025
| Implemented |
| 6400.171 | At the time of inspection, a ketchup bottle found in the upright refrigerator in the home's kitchen was missing its cap. This left the opening into the ketchup bottle unprotected and exposed the ketchup inside to contamination. | Food shall be protected from contamination while being stored, prepared, transported and served.
| QLHS staff identified an uncovered ketchup bottle stored in the facility refrigerator. To prevent potential contamination and uphold food safety standards, the bottle was promptly removed and discarded. Staff were reminded of proper food storage protocols to ensure all items are sealed and labeled appropriately |
11/01/2025
| Implemented |
| 6400.18(b)(2) | Per Individual #1's July 2025 Medication Administration Record (MAR), the individual was prescribed Cetirizine HCL 10mg tablet ("Take 1 tablet by mouth daily at 8am (allergies)") and Tab-A-Vite Tablet ("Take 1 tablet by mouth daily at 8am (supplement)"). Per the July 2025 MAR, both of these medications had the status "order pending provider review." On 07/11/2025, the MAR noted that Individual #1 was "physically unable to take" both of these medications. A 09/03/2025 phone discussion between this Licensing Representative and Newhard's Pharmacy facilitated by the provider agency revealed that these prescriptions were unable to be filled for the July fill date because they were out of refills and new prescriptions could not be obtained from the prescribing physician in time. Per documentation from the pharmacy, new prescriptions for these medications were not received from the prescribing physician until 07/24/2025. A delivery manifest shows that both medications were signed as delivered to Individual #1's home on 07/25/2025. Therefore, per documentation, these medications were unavailable to Individual #1 from 07/11/2025 through 07/24/2025.
The July 2025 MAR noted both of these medications as discontinued ("** SUSPENDED 11 Jul 2025 TO 18 Jul 2025: ON HOLD **"); however, there was no evidence that the prescribing physician issued an order to discontinue or hold the medications. As a formal order to discontinue these medications was not issued, Individual #1 was still prescribed both Cetirizine and Vite-A-Tab from 07/11/2025 through 07/24/2025; the July 2025 MAR shows that neither of these medications were administered to Individual #1 on those dates. The provider agency did not administer these medications to Individual #1 as prescribed.
There was no record that the provider agency entered an incident into the Enterprise Incident Management System (EIM) within 72 hours of their discovery of these medication errors after the missed doses on 07/11/2025. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person:
A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner. | QLHS staff identified an uncovered ketchup bottle stored in the facility refrigerator. To prevent potential contamination and uphold food safety standards, the bottle was promptly removed and discarded. Staff were reminded of proper food storage protocols to ensure all items are sealed and labeled appropriately |
11/01/2025
| Implemented |
| 6400.165(b) | Per Individual #1's July 2025 Medication Administration Record (MAR), the individual was prescribed Cetirizine HCL 10mg tablet ("Take 1 tablet by mouth daily at 8am (allergies)") and Tab-A-Vite Tablet ("Take 1 tablet by mouth daily at 8am (supplement)"). Per the July 2025 MAR, both of these medications had the status "order pending provider review." On 07/11/2025, the MAR noted that Individual #1 was "physically unable to take" both of these medications. A 09/03/2025 phone discussion between this Licensing Representative and Newhard's Pharmacy facilitated by the provider agency revealed that these prescriptions were unable to be filled for the July fill date because they were out of refills and new prescriptions could not be obtained from the prescribing physician in time. Per documentation from the pharmacy, new prescriptions for these medications were not received from the prescribing physician until 07/24/2025. A delivery manifest shows that both medications were signed as delivered to Individual #1's home on 07/25/2025. Therefore, per documentation, these medications were unavailable to Individual #1 from 07/11/2025 through 07/24/2025.
The provider agency failed to keep these prescription orders current by obtaining refills from the prescribing physician or from an alternative prescriber on an emergency basis. | A prescription order shall be kept current. | QLHS designated person scheduled another appointment for individual #1 to see the doctor for refills on Cetirizine HCL 10mg tablet and Tab-A-Vite Tablet and individual #1 is currently taking all prescribed medications. QLHS terminated the Supervisor that was responsible at the time of incident for not taking the individual #1 to his appointment to ensure that he had new scripts for his Cetirizine HCL 10 mg and Tab-A-Vite Tablet in his home.
QLHS staff and Administration was retrained on 9/12/25 by Lori Beidleman. |
09/12/2025
| Implemented |
| 6400.165(c) | Per Individual #1's August 2025 Medication Administration Record (MAR), the individual was prescribed Clonidine HCL 0.2mg Tablet ("Take 1 tablet by mouth daily at 8pm (HTN)"). The entries for the administration of this medication showed that it was administered at 8:00am from 08/01/2025 through 08/21/2025. Newhard's Pharmacy records showed that the pharmacy received an order from the prescribing physician to change the administration time for this medication from 8:00am to 8:00pm on 08/12/2025. New prescription labels were printed by Newhard's Pharmacy on 08/15/2025 and delivered to Individual #1's home at 9:30am that day. Therefore, as of 08/16/2025, Clonidine HCL should have been administered at 8:00pm. As this medication was incorrectly administered at 8:00am from 08/16/2025 through 08/21/2025, it was not administered as prescribed.
Per Individual #1's July 2025 MAR, the individual was prescribed Cetirizine HCL 10mg tablet ("Take 1 tablet by mouth daily at 8am (allergies)") and Tab-A-Vite Tablet ("Take 1 tablet by mouth daily at 8am (supplement)"). Per the July 2025 MAR, both of these medications had the status "order pending provider review." On 07/11/2025, the MAR noted that Individual #1 was "physically unable to take" both of these medications. A 09/03/2025 phone discussion between this Licensing Representative and Newhard's Pharmacy facilitated by the provider agency revealed that these prescriptions were unable to be filled for the July fill date because they were out of refills and new prescriptions could not be obtained from the prescribing physician in time. Per documentation from the pharmacy, new prescriptions for these medications were not received from the prescribing physician until 07/24/2025. A delivery manifest shows that both medications were signed as delivered to Individual #1's home on 07/25/2025. Therefore, per documentation, these medications were unavailable to Individual #1 from 07/11/2025 through 07/24/2025.
The July 2025 MAR noted both of these medications as discontinued ("** SUSPENDED 11 Jul 2025 TO 18 Jul 2025: ON HOLD **"); however, there was no evidence that the prescribing physician issued an order to discontinue or hold the medications. As a formal order to discontinue these medications was not issued, Individual #1 was still prescribed both Cetirizine and Vite-A-Tab from 07/11/2025 through 07/24/2025; the July 2025 MAR shows that neither of these medications were administered to Individual #1 on those dates. The provider agency did not administer these medications to Individual #1 as prescribed. | A prescription medication shall be administered as prescribed. | On 9/12/25, QLHS staff participated in a scheduled training session focused on Medication Administration procedures and the proper protocol for discontinuing medications. The training emphasized on accurate documentation of medication administration, verification procedures prior to administering medications, Steps for safely discontinuing medications, including physician orders and communication with pharmacy services, Compliance with ODP regulations.
All participating staff will sign attendance sheets and acknowledged understanding of the procedures. |
11/01/2025
| Implemented |
| 6400.165(e) | Per Individual #1's July 2025 Medication Administration Record (MAR), the individual was prescribed Cetirizine HCL 10mg tablet ("Take 1 tablet by mouth daily at 8am (allergies)") and Tab-A-Vite Tablet ("Take 1 tablet by mouth daily at 8am (supplement)"). Per the July 2025 MAR, both of these medications had the status "order pending provider review." On 07/11/2025, the MAR noted that Individual #1 was "physically unable to take" both of these medications. A 09/03/2025 phone discussion between this Licensing Representative and Newhard's Pharmacy facilitated by the provider agency revealed that these prescriptions were unable to be filled for the July fill date because they were out of refills and new prescriptions could not be obtained from the prescribing physician in time. Per documentation from the pharmacy, new prescriptions for these medications were not received from the prescribing physician until 07/24/2025. A delivery manifest shows that both medications were signed as delivered to Individual #1's home on 07/25/2025. Therefore, per documentation, these medications were unavailable to Individual #1 from 07/11/2025 through 07/24/2025.
The July 2025 MAR noted both of these medications as discontinued ("** SUSPENDED 11 Jul 2025 TO 18 Jul 2025: ON HOLD **"); however, there was no evidence that the prescribing physician issued an order to discontinue or hold the medications. Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. | Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received. | Individual #1 doctor did not receive a discontinue script for Cetirizine HCL 10mg and Tab-A-Vite Tablet. However, the supervisor transported the individual to see his primary doctor to request a new prescription for the medication missing. |
11/01/2025
| Implemented |
| 6400.166(a)(4) | Blister-packs of the following two Pro Re Nata (PRN) medications prescribed for Individual #1 were found in the home at the time of inspection: Mucinex DM ER 600-30MG Tab ("Take 1 tablet by mouth every 12 hours as needed for cough") and Acetaminophen 500mg Caplets ("Take 1 tablet by mouth every six hours as needed for moderate pain/headache or fever"). Neither of these medications had entries on Individual #1's September 2025 Medication Administration Record (MAR) as required. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | QLHS will assign the medication trainer on going into the Therp system to ensure that all medication entries are reviewed and completed to ensure that all medications are documented as required by ODP to ensure the health and safety of the individuals served. |
11/01/2025
| Implemented |