| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.104 | Individual #1 moved into the home on 7/3/2024. An updated fire department notification letter was not sent until 4/25/2025. | 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.
| , Compliance Manager, received training (Attachment 1) on the applicable 6400.104 regulation on 6/5/2025. |
06/05/2025
| Implemented |
| 6400.113(a) | Individual #1 received fire safety training on 4/9/2024, then not again until 4/29/2025. Additionally, Individual #1 moved into their current home on 7/3/2024 and they were not retained on fire safety upon admission into their new home. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually 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 and smoking safety procedures if individuals smoke at the home. | Individual #1 successfully completed Fire Safety Training (Attachment 2) on 6/4/2025. |
06/04/2025
| Implemented |
| 6400.144 | Individual #1's most recent physical dated 1/31/2025 states that they are diagnosed with a seizure disorder. Individual #1 regularly sees the neurologists to address seizure disorder, and on 11/8/2024, Individual #1 reported to their neurologists that they "think (they) had a seizure". Individual #1 also takes daily medication for a seizure disorder. There is no seizure plan or protocol for Individual #1 to address what their seizures look like, how they may be managed, or what to do if a seizure occurs.
· Individual #1 is prescribed the following medications as PRN that were not available in the home at the time of the physical site walkthrough: Pink Bismuth liquid 360ml, Saline Mist 0.65%, and Hyoscamine 0.125mg. | 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.
| On 6/2/2025, Director of Operations, requested that , the Neurodiverse Specialist assigned to the location, obtain documentation from Individual #1's neurologist outlining the recommended seizure protocol. On 6/6/2025, developed a draft seizure protocol (Attachment 10), which will be revised and finalized once the neurologist's recommendations have been obtained to ensure accuracy and alignment with medical guidance. Additionally, , Chief Financial and Operating Officer (CFOO), developed an agency wide Fatal Five Policy (Attachment 11) on 6/6/2025. |
06/06/2025
| Implemented |
| 6400.32(f) | Individual Rights signed by Individual #1 on 7/24/2023 and 5/23/2025 did not include the right for the Individual to be involved in decision making. | An individual has the right to refuse to participate in activities and services. | Individual #1 reviewed and signed the updated Individual Rights, Choices, and Services Policy (Attachment 3 & Attachment 4) on 6/4/2025. |
06/04/2025
| Implemented |
| 6400.32(r)(5) | Individual Rights signed by Individual #1 on 7/24/2023 and 5/23/2025 did not include the acknowledgement that direct service worker shall have a key to lock and unlock the Individual's bedroom door. | Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door. | Individual #1 reviewed and signed the updated Individual Rights, Choices, and Services Policy (Attachment 3 & Attachment 4) on 6/4/2025. |
06/04/2025
| Implemented |
| 6400.32(s)(3) | Individual Rights signed by Individual #1 on 7/24/2023 and 5/23/2025 did not include the acknowledgement that direct service worker shall have a key to lock and unlock the entrance door of the home. | Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door. | Individual #1 reviewed and signed the updated Individual Rights, Choices, and Services Policy (Attachment 3 & Attachment 4) on 6/4/2025. |
06/04/2025
| Implemented |
| 6400.32(t) | Individual Rights signed by Individual #1 on 7/24/2023 and 5/23/2025 did not include the right for the Individual to have access to food. | An individual has the right to access food at any time. | Individual #1 reviewed and signed the updated Individual Rights, Choices, and Services Policy (Attachment 3 & Attachment 4) on 6/4/2025. |
06/04/2025
| Implemented |
| 6400.32(v) | Individual Rights signed by Individual #1 on 7/24/2023 and 5/23/2025 did not include Individual's rights may only be modified to mitigate health and safety risk to Individual and others. | An individual's rights may only be modified in accordance with § 6400.185 (relating to content of the individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others. | Individual #1 reviewed and signed the updated Individual Rights, Choices, and Services Policy (Attachment 3 & Attachment 4) on 6/4/2025. |
06/04/2025
| Implemented |
| 6400.33(a) | Individual Rights signed by Individual #1 on 7/24/2023 and 5/23/2025 did not include Individual's rights to be exercised to that another individual's rights are not violated. | An individual's rights shall be exercised so that another individual's rights are not violated. | Individual #1 reviewed and signed the updated Individual Rights, Choices, and Services Policy (Attachment 3 & Attachment 4) on 6/4/2025. |
06/04/2025
| Implemented |
| 6400.33(b) | Individual Rights signed by Individual #1 on 7/24/2023 and 5/23/2025 did not include that the provider shall assist the individual to negotiate choices. | The Provider shall assist the affected individuals to negotiate choices in accordance with the Provider's procedures for the individuals to resolve differences and make choices. | Individual #1 reviewed and signed the updated Individual Rights, Choices, and Services Policy (Attachment 3 & Attachment 4) on 6/4/2025. |
06/04/2025
| Implemented |
| 6400.34(a) | Individual #1 was informed of their individual rights on 7/24/2023, then not again until 5/26/2025. Provider identified the missing 2024 individuals' rights statement on their 30-day self-assessment document, prior to licensing. However, the self-citation was not fully corrected until 5/26/2025, which is after the provider's annual inspection began and following when the inspection sample was already provided to the provider (5/23/2025). | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | , Program Specialist, completed training (Attachment 5) on the applicable 6400.34(a) regulation on 6/5/2025. |
06/05/2025
| Implemented |
| 6400.165(b) | Individual #1's May 2025 Medication Administration Record (MAR) states that they are prescribed medication, Gavilax Powder as PRN. This medication is not available in the home, and the prescriber discontinued this medication in August 2024, however the MAR has not been updated accordingly. | A prescription order shall be kept current. | On 6/5/2025, , Director of Training, updated Individual #1's Medication Administration Record (Attachment 14) to reflect the discontinuation of the Gavilax Powder and it has been removed accordingly. |
06/05/2025
| Implemented |
| 6400.166(a)(2) | Individual #1's March and April 2025 Medication Administration Record does not include the prescriber for Citalopram 20 mg tablet, Lamotrigine 200 mg tablet, Risperidone 0.25 mg tablet, and Rosuvastatin 5mg tablet. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | On 6/5/2025, , Director of Training, updated Individual #1's Medication Administration Record (Attachment 6) to include all previously missing prescriber information. |
06/05/2025
| Implemented |
| 6400.166(a)(11) | · Individual #1 was prescribed Amox-Clav 875-125mg tablets to be taken 1 tablet by mouth 2 times daily for 7 days beginning 5/10/25. There is no diagnosis or purpose for this medication recorded on the May 2025 Medication Administration Record.
· Individual #1 is prescribed Clearlax Powder 17 gram/dose, Resperidone 0.25mg tablet, Rosuvastin 5mg tablet. March, April, and May 2025 Medication Administration record does not include the diagnosis or purpose of the medication.
· Individual #1 was prescribed Doxycycline Hyclate 100 mg cap to be taken 1 capsule by mouth 2 times daily (with meals) for 7 days beginning on 5/10/2025. There is no diagnosis or purpose for this medication recorded on the May 2025 Medication Administration Record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | , Director of Training, received training (Attachment 7 & Attachment 9) on the applicable 6400.166(a)(11) regulation on 6/5/2025. On 6/5/2025, , Director of Training, updated Individual #1's Medication Administration Record (Attachment 8) to include all previously omitted medication diagnoses. |
06/05/2025
| Implemented |