| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | The individual funds shall be used for the individual's benefit. The individual had several Walmart receipts in his expense log that reflects he is regularly purchasing grocery and hygiene products such as; bananas, watermelon, peaches, mushrooms, onions, maxwell house coffee, sugar, tomatoes, apples, chocolate milk, cucumbers, bulk corn, and suave soap. These items should be included in the room and board and should not be regular purchases made with individual's own resources. | Individual funds and property shall be used for the individual's benefit. | Provider reimbursed individual for items covered by Room and Board.-please see attached items and copy of check. A meeting was held with his Supports Coordinator to include information in the ISP as to this individual wanting to purchase items already paid for by the provider and available in the home from an education standpoint to staff and the individual. Provider will be sure to pay for items covered by Room and Board. |
01/07/2026
| Implemented |
| 6400.104 | The agency shall notify the local fire dept in writing of the address of the home and the exact location of bedrooms of individual's who may need assistance in evacuating in the event of a fire. The agency provided a "notification to the fire dept letter" dated 4.27.22. This letter did not list the address or the location of the bedrooms in the home and if anyone needed assistance. The letter informed the fire dept that the agency operates a group home for people with intellectual disabilities and they are looking to open a new home in their designated area of service and provided informational sheets for the home. However, that information was not noted on the copy they retained for their records and it is unclear if the dept has the correct and most up to date information. In addition there is a new individual living in the home and his date of admission was 4.4.2025, and the notification that was provided to me was from 4.27.2022. The letters shall be kept current. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Provider corrected the documentation and sent to the Fire Chief on 12/31/2025 that contained the location of the individual's bedroom.-please see document submitted. |
12/31/2025
| Implemented |
| 6400.144 | Individual was seen at his doctor for a follow visit from the ER on 6.30.25. At this apt individual was referred to have a Dexa Scan completed. There was no documentation to reflect that test was scheduled or completed. | 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.
| Individual had Dexa Scan performed on 1/7/26 and discussed with medical provider on 1/15/26. |
01/07/2026
| Implemented |
| 6400.211(b)(1) | The emergency record does not have an emergency contact listed with the name, address and number of the individual to be contacted in the event of an emergency. | Emergency information for each individual shall include the following: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency.
| Information was added to the Facesheet for Emergency Contact person.-please see submitted document |
01/02/2026
| Implemented |
| 6400.211(b)(3) | The emergency record did not identify a person able to provide consent for emergency medical needs. | Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.
| Information was added to the Facesheet for persons able to give consent for emergency medical treatment. |
01/02/2026
| Implemented |
| 6400.163(a) | Prescription and non prescription medications shall be kept in their original lableld containers. Prescription medications shall be labeled with a label issued by a pharmacy. The individual is prescribed an epipen for allergic reactions. The epi pen that was provided to me at the time of the inspection was not labeled. It was unclear who the pen was for or what the directions were as it was just the pen in a zip up bag. After leaving the home, the agency provided a photo of a pharmacy labeled box containing the individual prescribed epi pen. This serves as the plan of correction as the dispense date was 12.29.25 and it was provided after the inspection took place. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | Provider Residential Director provided the image of 12/29/25 EpiPen box with a label. |
12/29/2025
| Implemented |
| 6400.163(h) | Prescriptions that are expired shall be destroyed in a safe manner. Individual is prescribed hydrocortisone cream to be applied as needed. The cream was dispensed on 12.3.24, and was opened and used at some point. It is typically a year from the dispense date once the product is opened. There was a newer unopened Hydrocortisone cream also with the PRN medications that is current. The expired cream shall be disposed. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Residential Director destroyed the expired medication and removed it from the home on 12/29/25. |
12/29/2025
| Implemented |
| 6400.165(g) | The individual had medication reviews on 5.16.25, 6.9.25, 9.12.25, 11.5.25, and on 12.4.25. All of these medication reviews did not include the name of the medication or the necessary dosage. Medication reviews shall include the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Residential Director did not file the Medication list with the Psychiatric Medication Review that contained the name of the medication and the dosage. "see attached" was written to the Psychiatric Provider. The 3 Month Review form lists the Diagnosis-Reason for Prescribing, Behaviors, Medical Provider Remarks including to continue or discontinue with responses documented-please see submitted documents Residential Director will retain a copy of the Medications List to be filed next to the Review document itself moving forward. |
01/02/2026
| Implemented |
| 6400.210(b)(2) | The emergency record shall have the name, address and phone number of the primary care physician. The document was missing the address of the physician. | An individual's personal funds or property may not be used as payment for damages unless the individual consents to make restitution for the damages. The following consent provisions apply unless there is a court-ordered restitution: Consent shall be obtained in the presence of the individual or a person designated by the individual. | Information was added to the Facesheet for the address of the Primary Care Physician.-please see submitted document |
01/02/2026
| Implemented |