| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.70 | The telephone in the home did not have an operable line at the time of the inspection. The telephone did not have a dial tone, and it was not possible to make outgoing calls from the phone. The phone also did not receive incoming calls; incoming calls went directly to voice mail. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| Provider contacted the landline provider RCN Astound who reported to the home and replaced defective wiring. |
01/06/2026
| Implemented |
| 6400.141(c)(4) | The annual physical examination completed on 5/05/2025 for Individual #1 did not document that a hearing screening occurred. The physical examination form states that the individual's ears were checked but does not mention if basic hearing was assessed. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Provider has edited the Annual physical form to use specific regulatory wording for Vision and Hearing recommendation.-please see submitted document. Residential Director has since scheduled an appointment with an audiologist scheduled for 2/3/2026. |
01/06/2026
| Implemented |
| 6400.144 | Health services that are planned or prescribed for the individual shall be arranged for or provided. The annual physical examination completed on 5/05/2025 for Individual #1 recommended that the individual continue routine eye exams but there was no documentation in the record that the individual had an eye appointment with an eye doctor in the past year. | 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.
| Annual Physical documents a vision screening by the PCP. Residential Director since scheduled an Eye/Vision examination for this individual held on 1/29/26 the Dr. cancelled the appointment as the individual would not cooperate with the examination by refusing to open his eyes-please see submitted document. |
01/29/2026
| Implemented |
| 6400.151(c)(4) | The initial physical examination completed on 6/09/2025 for Staff #1 did not document whether the staff had any medical problems which might interfere with the health of the individuals. | The physical examination shall include: Information of medical problems which might interfere with the health of the individuals. | This particular staff person is no longer employed at the provider agency. The Staff Physical forms will receive greater/additional scrutiny of a second review by the HR assistant moving forward to avoid any blanks/omitted information. |
01/06/2026
| Implemented |
| 6400.163(h) | Prescription medications that are discontinued or expired shall be destroyed in a safe manner. The medication Zolpidem 10 mg. tablets were discontinued but a blister pack of the medication was found with the current medications for Individual #1. A tube of bacitracin ointment, with an expiration date of 6/2025 was found stored with individual #1's current medications. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Residential Director safely destroyed and removed the expired ointment from the home at the time of inspection. |
12/30/2025
| Implemented |
| 6400.183(c) | The list of persons who participated in the individual plan meeting shall be kept. A copy of the list of persons who participated in the individual plan meeting for Individual #1 was not available in the Individual's record. | The list of persons who participated in the individual plan meeting shall be kept. | Provider agency has created a new form (in house) to record the participants of the ISP plan meeting that will be retained by the provider agency. |
01/06/2026
| Implemented |