| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | The running water returned with a temperature of 129.2F; exceeding the allowable threshold of 120.0F. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Our monthly fire drill form was updated to include a section that now requires the water temperature to be checked and the temperature noted on the fire drill form. If above 120 degrees the supervisor or on-call is to be notified immediately. |
10/07/2025
| Implemented |
| 6400.144 | Individual #1 was prescribed the medication Albuterol as a PRN according to the MAR but it was not available during inspection. | 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 medication in question had been discontinued, however, the discontinuation paperwork had not been provided to the pharmacy so it was not removed from the MAR. The pharmacy and doctor's office were both contacted and the appropriate paperwork provided and the medication was removed from the MAR. On 10/3/2025 the SA trainer went to the home and completed a medication re-training for all of the staff who work at the site. |
10/07/2025
| Implemented |
| 6400.216(a) | There were records being kept in the basement of the home which is unlocked and there was not a lockable cabinet. | An individual's records shall be kept locked when unattended.
| The records, in this instance, had been removed from the files and placed in a box in preparation to be a taken to the main office for a shredding event. The box was overlooked and was not removed from the site. Going forward we will ensure that any files that are removed from the books, which are kept in a locked cabinet, will only be done so immediately before the shredding event and not kept at the house. |
10/07/2025
| Implemented |