| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(b) | At the time of inspection, a ping-pong-ball-sized accumulation of lint was located in the lint trap of the home's dryer. This accumulation of lint was sufficient to constitute a fire hazard within the home. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Lint was immediately removed by the licensing agent. |
12/11/2025
| Implemented |
| 6400.141(c)(3) | Individual #1's most recent physical examination, dated 11/07/2025, did not contain the individual's Immunization History. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Immunizations were located and attached to physical. |
12/18/2025
| Implemented |
| 6400.144 | Per Individual #1's December 2025 Medication Administration Record (MAR), the individual was prescribed the following Pro Re Nata (PRN) psychotropic medication: Hydroxyz HCL Tablet 25mg, "Take 1 capsule by mouth twice a day as needed for anxiety." In order to administer a PRN psychotropic medication, which is considered to be a chemical restraint, additional criteria must be met by the provider. In this case, the provider failed to meet the following two criteria:
1. The medication's prescription label did not note the specific and observable symptoms of psychiatric illness that would necessitate the administration of the PRN psychotropic medication, i.e., pacing back and forth, chewing on fingers, etc.
2. The provider did not implement a protocol requiring that staff administering the PRN psychotropic medication contact the Chief Executive Officer (CEO) or provider staff designated by the CEO for permission prior to administering the medication.
By failing to meet these criteria, the provider failed to implement pharmaceutical services for Individual #1. | 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 #1's current psychiatrist was contacted to update the Hydroxyz PAM prescription to indicate specific symptoms for administering the medication, which only occurs when the individual specifically requests the medication for anxiety. Individual #1's skills assessment was updated to reflect her ability to request this medication. |
12/12/2025
| Implemented |
| 6400.181(a) | Per Individual #1's Individual Record, the individual's two most recent Individual Assessments were issued on 05/11/2024 and 06/11/2025---more than one year apart. An Individual Assessment was not conducted for this individual at least annually as required. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Individual #1's skills assessment was reviewed and ensured it was correct and updated. |
12/18/2025
| Implemented |
| 6400.165(g) | Individual #1 is prescribed psychotropic medications for the treatment of mental health conditions and sees a psychiatrist for psychotropic medication management. Per the Individual Record, medication reviews occurred on 02/12/2025, 04/07/2025, 06/06/2025, 07/25/2025, 09/19/2025, and 12/05/2025; however, the documentation accompanying these appointments was missing the following required information: a list of psychotropic medications, the reason for prescribing each medication, and the necessary dosage of each medication. | 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. | Individual has a psych appointment scheduled on 1/6/2025 and the correct form was made available in the home to take to the appointment. |
12/18/2025
| Implemented |