Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00280056 Renewal 12/18/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(1)Individual #1's Physical Examination, dated 07/02/2025, did not include a review of the individual's medical history. The physical form had a section labeled, "Diagnoses/Significant Health Conditions (Include a Medical History and Chronic Health Conditions)," which was left blank with a note to "See Attached;" however, as there was no additional information attached to the physical form, it could not be established that a review of the individual's medical history took place during the Physical Examination.The physical examination shall include: A review of previous medical history. 6400.141 (c) (1)T he physical examination shall include: A review of previous medical history. During the site inspection by ODP on December 18, 2025, a violation was issued for individual #1's Physical Examination, dated 07/02/2025, because it did not include a review of the individual's medical history. The physical form had a section labeled, "Diagnoses/Significant Health Conditions (Include a Medical History and Chronic Health Conditions)," which was left blank with a note to "See Attached;" however, as there was no additional information attached to the physical form, it could not be established that a review of the individual's medical history took place during the Physical Examination. On January 5, 2026, the supervisor contacted the PCP's office of Individual #1 and requested a copy of the medication regimen located on the discharge summary for the 7/02/25 visit. This information was added to individual #1s file. 01/05/2026 Implemented
6400.141(c)(4)Individual #1's Physical Examination, dated 07/02/2025, did not include a hearing examination. There was a portion of the physical form that allowed the physician to recommend for or against a hearing examination; however, as this portion of the physical form was left blank, it could not be determined whether the physician intended the individual to have their hearing evaluated. There was no record of a hearing examination occurring within the review period elsewhere in the Individual Record.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. 6400.141 (c) (4) The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. During the site inspection, a violation was issued for individual #1's Physical Examination, dated 07/02/2025, did not include a hearing examination. There was a portion of the physical form that allowed the physician to recommend for or against a hearing examination; however, as this portion of the physical form was left blank, it could not be determined whether the physician intended the individual to have their hearing evaluated. There was no record of a hearing examination occurring within the review period elsewhere in the Individual Record. On January 9, 2026, the supervisor took the individual back to the PCP office and the hearing exam was completed and documented. She will also have another physical on 5/22/26 scheduled. She has a vision examination scheduled for 2/11/26. 01/09/2026 Implemented
6400.141(c)(11)Individual #1's Physical Examination, dated 07/02/2025, did not include a medication regimen for the individual. There was an area of the physical form designated for this information; however, it was left blank with a note to "See Attached." As there were no additional documents attached to the physical form, it could not be established that an assessment of the individual's medication regimen occurred during the Physical Examination.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. 6400.141 (c) (11) The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. During the site inspection, Individual #1's Physical Examination, dated 07/02/2025, did not include a medication regimen for the individual. There was an area of the physical form designated for this information; however, it was left blank with a note to "See Attached." As there were no additional documents attached to the physical form, it could not be established that an assessment of the individual's medication regimen occurred during the Physical Examination. On January 5, 2026, the supervisor contacted the PCP's office of Individual #1 and requested a copy of the medication regimen located on the discharge summary for the 7/02/25 visit. This information was added to individual #1s file 01/05/2026 Implemented
6400.141(c)(13)Individual #1's Physical Examination, dated 07/02/2025, did not include a list of the individual's allergies or contraindicated medications, if any---the area of the physical form designated for this information was left blank. It could not be determined if the individual does not have any allergies or contraindicated medications or if this information was omitted from the form in error.The physical examination shall include: Allergies or contraindicated medications.6400.141 (c) (13) The physical examination shall include: Allergies or contraindicated medications. Individual #1's Physical Examination, dated 07/02/2025, did not include a list of the individual's allergies or contraindicated medications on the area of the physical form designated for this information. It could not be determined if the individual does not have any allergies or contraindicated medications, or if this information was omitted from the form in error. On December 22, 2025, the supervisor contacted the PCP office and requested that this information be filled in on the form. The completed information was added to Individual #1's medical records. 12/22/2025 Implemented
6400.142(c)Individual #1's Individual Record contained evidence that the individual attended dental examinations and cleanings at a dental practice called "Smiles 4 Keeps" on 01/06/2025 and 07/08/2025 in the form of incomplete appointment forms. These forms lacked the following required information: the dentist's name, procedures completed, and follow-up treatment recommended, if any.A written record of the dental examination, including the date of the examination, the dentist's name, procedures completed and follow-up treatment recommended, shall be kept. 6400.142 (c) A written record of the dental examination, including the date of the examination, the dentist's name, procedures completed and follow-up treatment recommended, shall be kept. A violation was issued because individual #1's Individual Record contained evidence that the individual attended dental examinations and cleanings at a dental practice called "Smiles 4 Keeps" on 01/06/2025 and 07/08/2025. The form did not contain al 6400 requirements (dentist's name, procedures completed, and follow-up treatment recommended, if any). The form was reviewed on January 12, 2026 and updated to include the correct information. See attachment 9 for a copy of the updated form. 01/12/2026 Implemented
6400.142(d)Individual #1's Individual Record contained evidence that the individual attended dental examinations and cleanings at a dental practice called "Smiles 4 Keeps" on 01/06/2025 and 07/08/2025 in the form of incomplete appointment forms. These forms lacked the following required information: the dentist's name, procedures completed, and follow-up treatment recommended, if any. As these appointment forms did not include a record of the procedures completed at the dental appointments, it could not be established that either of these visits included teeth cleaning or checking of gums and dentures.The dental examination shall include teeth cleaning or checking gums and dentures. 6400.142 (d) The dental examination shall include teeth cleaning or checking gums and dentures. A citation was issued to LVHS on December 18, 2025 during the ODP site inspection because Individual #1's Individual Record contained evidence that the individual attended dental examinations and cleanings at a dental practice called "Smiles 4 Keeps" on 01/06/2025 and 07/08/2025 in the form of incomplete appointment forms. The form did not contain all 6400 requirements. Specifically, the form lacked documentation of the procedures completed at the dental appointments. It could not be established that either of these visits included teeth cleaning or checking of gums and dentures. These forms lacked the following required information: the dentist's name, procedures completed, and follow-up treatment recommended, if any. As these appointment forms did not include a record of the procedures completed at the dental appointments, it could not be established that either of these visits included teeth cleaning or checking of gums and dentures. The form was reviewed on January 12, 2026 and updated to include the correct information. See attachment 9 for a copy of the updated form. 01/12/2026 Implemented
6400.144Per Individual #1's December 2025 Medication Administration Record (MAR), the individual was prescribed Vitamin D2 1.25Mg (50,000 Unit) with instructions to "Take one capsule by mouth once a week for Vitamin D deficiency" and Loperamide 2mg capsule with instructions to "Take one capsule by mouth 4 times daily as needed for diarrhea." At the time of inspection, these prescription medications could not be located within the home. As such, the provider failed to arrange pharmaceutical services for the individual.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. 6400.144 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. Per Individual #1's December 2025 Medication Administration Record (MAR), the individual was prescribed Vitamin D2 1.25Mg (50,000 Unit) with instructions to "Take one capsule by mouth once a week for Vitamin D deficiency" and Loperamide 2mg capsule with instructions to "Take one capsule by mouth 4 times daily as needed for diarrhea." At the time of inspection, these prescription medications could not be located within the home. As such, the provider failed to arrange pharmaceutical services for the individual. The medication has since been placed in the home by the supervisor when arrived from the pharmacy. 01/05/2026 Implemented
6400.151(a)Staff #2 was hired effective 03/04/2025. Per the Staff Record, this staff did not have a physical examination completed until 03/09/2025. This staff did not have a physical examination completed within 12 months prior to their date of hire as required. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. 34. According to 6400.151 (a) staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Staff #2 was hired effective 03/04/2025. Per the Staff Record, this staff did not have a physical examination completed until 03/09/2025. This staff did not have a physical examination completed within 12 months prior to their date of hire as required. This supervisor was required to complete a review of 6400.151 (a) This was completed on January 5, 2026. 01/05/2026 Implemented
6400.151(c)(2)Staff #2 was hired effective 03/04/2025. Per the Staff Record, this staff did not have a physical examination completed until 03/09/2025. Per the physical examination form, a Mantoux test was placed on 03/09/2025 and read negative on 03/11/2025. This staff member did not have tuberculin testing with a negative result as a component of the initial staff physical examination, within 12 months prior to their date of hire as required. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. 6400.151 (c) (2)The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. However, Staff #2 was hired effective 03/04/2025. Per the Staff Record, this staff did not have a physical examination completed until 03/09/2025. Per the physical examination form, a Mantoux test was placed on 03/09/2025 and read negative on 03/11/2025. This staff member did not have tuberculin testing with a negative result as a component of the initial staff physical examination, within 12 months prior to their date of hire as required. This supervisor was required to complete a review of 6400.151 (a) This was completed on January 5, 2026. 01/05/2026 Implemented
6400.32(r)The Individual Support Plan for Individual #1 reports that the individual's bedroom door is equipped with a "key code lock" This is not accurate. Individual #1's bedroom door lock is a "privacy lock". This type of lock can be opened with a tool or device that is not specific to the door or lock, such as, a screwdriver or coin. These types of locks do not provide the level of privacy and security of person and possessions expected by this regulation.An individual has the right to lock the individual's bedroom door.6400.32 (r) states that an individual has the right to lock the individual's bedroom door. The Individual Support Plan for Individual #1 reports that the individual's bedroom door is equipped with a "key code lock" This is not accurate. Individual #1's bedroom door lock is a "privacy lock". This type of lock can be opened with a tool or device that is not specific to the door or lock, such as, a screwdriver or coin. These types of locks do not provide the level of privacy and security of person and possessions expected by this regulation. On December 19, 2025 a lock was placed on the door in question. See attachment 10 for photo of the lock on the door. 12/19/2025 Implemented
6400.46(a)Staff #1 was hired effective 07/15/2024. The Staff Training Record did not contain evidence that this staff completed Fire Safety Training during their orientation training or within the remainder of the 2024 training year. This staff completed a Fire Safety Training on 10/22/2025; however, as there was no evidence that a Fire Safety Training was completed by this staff during the 2024 training year, it could not be established that this training was conducted annually as required. Staff #2 was hired effective 03/04/2025 and first worked with individuals on 03/12/2025. Per the Staff Record, this staff's only Fire Safety Training occurred on 10/22/2025. This staff did not receive training in Fire Safety prior to working with individuals as required.Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.38. 6400.46 (a) indicates that the Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. Staff #1 was hired effective 07/15/2024. The Staff Training Record did not contain evidence that this staff completed Fire Safety Training during their orientation training or within the remainder of the 2024 training year. This staff completed a Fire Safety Training on 10/22/2025; however, as there was no evidence that a Fire Safety Training was completed by this staff during the 2024 training year, it could not be established that this training was conducted annually as required. Staff #2 was hired effective 03/04/2025 and first worked with individuals on 03/12/2025. Per the Staff Record, this staff's only Fire Safety Training occurred on 10/22/2025. This staff did not receive training in Fire Safety prior to working with individuals as required. The staff was immediately trained on fire safety (December 22, 2025). See attached sign-off sheets for fire safety training. Staff has been retrained on Fire Safety on 12/22/25 12/22/2025 Implemented
6400.166(a)(10)Per Individual #1's December 2025 Medication Administration Record (MAR), the individual was prescribed Vitamin D2 1.25Mg (50,000 Unit) with instructions to "Take one capsule by mouth once a week for Vitamin D deficiency" and Humira Pen 40mg/0.4ml with instructions to "Inject 1 pen under skin every 14 days for Rheumatoid Arthritis." The MAR entries for these medications lacked administration times.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times.39. In accordance with 6400.166 (a) (10) medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. Per Individual #1's December 2025 Medication Administration Record (MAR), the individual was prescribed Vitamin D2 1.25Mg (50,000 Unit) with instructions to "Take one capsule by mouth once a week for Vitamin D deficiency" and Humira Pen 40mg/0.4ml with instructions to "Inject 1 pen under skin every 14 days for Rheumatoid Arthritis." The MAR entries for these medications lacked administration times. The supervisor contacted Individual#1's PCP to request times of administration. The doctor sent an order on December 19, 2025 and the individual was administered medication at these times. 12/19/2025 Implemented
6400.181(f)Individual #1's most recent Individual Plan Meeting occurred on 03/25/2025. There was no evidence that either Individual #1's Initial Individual Assessment, dated 10/26/2024, or Individual #1's most recently revised Individual Assessment, dated 01/30/2025, were sent to members of the Individual Plan Team by the Program Specialist at least 30 calendar days prior to the Individual Plan Meeting as required.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.40. 6400.181 (f) indicates that the program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. However, Individual #1's most recent Individual Plan Meeting occurred on 03/25/2025. There was no evidence that either Individual #1's Initial Individual Assessment, dated 10/26/2024, or Individual #1's most recently revised Individual Assessment, dated 01/30/2025, were sent to members of the Individual Plan Team by the Program Specialist at least 30 calendar days prior to the Individual Plan Meeting as required. The PS sent the assessment to the SC on December 22, 2025. 12/22/2025 Implemented
6400.183(c)Individual #1's Individual Record did not contain a record of the participants attending the individual's 03/12/2025 Individual Plan Meeting.The list of persons who participated in the individual plan meeting shall be kept.6400.183 (c) states that the list of persons who participated in the individual plan meeting shall be kept. During the site inspection a citation was issued because Individual #1's Individual Record did not contain a record of the participants attending the individual's 03/12/2025 Individual Plan Meeting. Program Specialist is aware to keep an attendance sheet. 01/07/2026 Implemented
6400.186Individual #1's bedroom door lock is a "privacy lock". This type of lock can be opened with a tool or device that is not specific to the door or lock, such as, a screwdriver or coin. The Individual Support Plan (ISP) for Individual #1 states that the individual requires a "key code" lock. The ISP was not implemented.The home shall implement the individual plan, including revisions.42. 6400.186 The home shall implement the individual plan, including revisions. However, on December 18, 2025 during the site inspection, a citation was issued because Individual #1's bedroom door lock is a "privacy lock". This type of lock can be opened with a tool or device that is not specific to the door or lock, such as, a screwdriver or coin. The Individual Support Plan (ISP) for Individual #1 states that the individual requires a "key code" lock. The ISP was not implemented. On December 19, 2025 a lock was placed on the door in question. See attachment 10 for photo of the lock on the door. 12/19/2025 Implemented
SIN-00261243 Renewal 03/19/2025 Compliant - Finalized