| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The kitchen cabinets had a layer of a sticky substance consistent with grease. | Clean and sanitary conditions shall be maintained in the home. | The Service Director of the site personally cleaned the kitchen cabinets to address the grease substance that had accumulated. The cleaning was completed thoroughly, and all visible grease was removed. |
06/03/2025
| Implemented |
| 6400.112(c) | The fire drill record for the drill conducted on 11/26/2024 did not record the evacuation time. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | The Service Director reviewed and corrected the fire drill documentation for November 26, 2024, which was previously missing the evacuation time. The form has been updated to accurately reflect the evacuation details. |
06/03/2025
| Implemented |
| 6400.151(c)(2) | Initial physical examinations must include a tuberculosis (TB) test with negative results, or, if positive, an initial chest x-ray with results noted. The initial physical examination for Staff #5 occurred on 1/14/2025 but did not include a TB test. A chest x-ray was completed on 1/14/2025 but there was no documentation on the physical examination form or the radiology report to indicate that the staff person had a TB test completed with a positive result, or a history of positive TB test results. | 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. | The provider updated the employee Physical forms to reflect that if a new hire needs a Chest X-Ray, that the reason why it is needed is listed. Also, for current employees, the tuberculosis (TB) test is no longer required after the initial physical, so the tuberculosis (TB) portion for current employees was removed. All new hire employees will still be required to get a tuberculosis (TB) test. |
06/03/2025
| Implemented |