| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.133(b) | The Individual Support Plan last updated on 8/17/25 it is noted that Individual #1 is not self-medicating. At the time of inspection, the medication Methylphenidate was in a small pill box labeled S-M-T-W-TH-F-S. Pills remained in the W-TH-F-S compartments. prescription medication may not be removed from its original labeled container in advance of the scheduled administration. | A prescription medication may not be removed from its original labeled container in advance of the scheduled administration, except for the purpose of packaging the medication for the individual to take with the individual to a community activity for administration the same day the medication is removed from its original container. | As of 8/27/2025, individual #1¿s small pill box is no longer used. All his medications now are kept their original labeled container. |
08/27/2025
| Implemented |
| 6500.135(c) | Individual #1 is prescribed Polyethylene Glycol to be taken "Take one heaping tablespoon 17g with 8oz of water daily." At time of inspection a bottle of Polyethylene Glycol was presented as in use for Individual #1. The bottle was pharmacy labeled as filled on 6/20/25. At time of inspection on 8/26/25 the bottle in use was unopened. Administered as prescribed the bottle would have been empty by approximately 7/27/25. | A prescription medication shall be administered as prescribed. | As of 8/27/2025, life sharing provider was counseled on properly administration of medication. |
08/27/2025
| Implemented |
| 6500.137(a)(7) | At time of inspection Individual #1 was being administered Azelastine nasal spray with directions to "Spray 1-2 sprays into each nostril twice a day as directed." The August 2025 Medication Administration Record for Individual #1 did not note the dose that was administered at each administration as required. Staff #1 reported that Individual #1 would use one spray while Individual #1 noted that they would use 2 sprays. The number of sprays or dose of medication was not recorded at the time of administration. | Medication errors include the following: Administration while the individual is in the wrong position. | As of 9/15/25, Program Specialist worked with ECP (web ¿ based software) to update med pass to include recording of the number of sprays or dose of medication at the time of administration. Life sharing provider is now able to record the number of sprays or dose of medication at the time of administration. |
09/15/2025
| Implemented |