| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | Individual #1's record contains a 10/27/25 receipt for $35.66 in the record; Individual #1 paid for 2 orders of chicken wings with French fries, pork fried rice, and 2 pork eggrolls; twice more food than they normally order and similar to an order that was split with a staff member on 10/13/25.
Individual #1 purchased a 32 pack of "CVS Men Unw L/X" incontinence briefs for $20.79 from CVS on 07/04/2025; this item is included in the Room and Board contract as a provider expense. Individual #1 also purchased the same item from CVS on 05/31/25. | Individual funds and property shall be used for the individual's benefit. | An EIM report was entered, and an investigation began immediately upon discovery. During the investigation, the CI interviewed the rep payee, who confirmed they had instructed staff to purchase an additional meal using Individual #1's funds during community outings.
It was also confirmed that the pork fried rice included in the October 27, 2025, purchase was bought for the staff member and not for the individual. Staff were counseled and reminded that individual funds may not be used to purchase food or items for staff under any circumstance.
The improper food charges and the incontinence briefs purchased on 07/04/25 and 05/31/25, items that are the provider's responsibility under the Room & Board contract, were reimbursed to Individual #1's account in full.
A complete review of all individuals' financial records was conducted to determine if similar errors occurred. Any discrepancies found were corrected, and reimbursements were issued as needed.
See attachments #1, #2, & #3. |
12/12/2025
| Implemented |
| 6400.22(e)(3) | Individual #1's record contains a 08/25/25 handwritten receipt for $20 "food and drink"; the receipt does not indicate what was purchased or where it was purchased. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | The program manager reviewed the 08/25/25 handwritten receipt for "food and drink" totaling $20 and confirmed it did not meet documentation requirements. The receipt did not identify the items purchased or the location, and handwritten entries are not acceptable for documenting purchases over $15.
See attachments 1 & 3.
The staff member responsible was counseled and reminded that all purchases must be supported by an actual, itemized receipt from the vendor. Handwritten receipts will no longer be accepted under any circumstance.
A full review of all individuals' financial records was completed. Any handwritten entries or incomplete receipts were corrected, and missing documentation was obtained from staff or the vendor as appropriate.
The total amount was reimbursed to Individual #1's account in full. |
12/12/2025
| Implemented |
| 6400.141(c)(10) | Individual #1 02/27/25 Physical states that Individual #1 is not free from communicable diseases; the form does not state what the communicable disease is or what precautions to take to avoid the spread of the disease. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | The program manager contacted the primary care provider to request clarification regarding the communicable disease noted on the 02/27/25 physical. An updated physical examination form was obtained that specifies the communicable condition and includes the required precautions to prevent the spread of the disease. The corrected form has been filed in the individual's medical record.
A full review of all individuals' physicals was conducted to ensure that any physical indicating a communicable disease includes specific instructions and precautions. Any missing information was corrected by contacting the medical providers for updated documentation.
Staff responsible for reviewing and filing physicals were counseled and reminded not to accept or file physicals that indicate a communicable disease without the required detail.
See attached #4. |
12/12/2025
| Implemented |
| 6400.181(a) | Individual #1's Initial Assessment was completed 07/07/25, more than 60 days after the Date of Admission of 04/28/25. | 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. | The program specialist reviewed the admission timeline for Individual #1 and confirmed that the initial assessment completed on 07/07/25 exceeded the 60-day requirement following the admission date of 04/28/25.
A review of all other individuals' admission and assessment timelines was completed to ensure compliance with the 60-day requirement. No additional late assessments were found.
Staff responsible for completing initial assessments were counseled regarding the regulatory requirement and the need to ensure timely completion of all admission-related documentation.
See attached #5. |
12/12/2025
| Implemented |
| 6400.32(d) | Individual #1's 07/07/25 Annual Assessment states that Individual #1 is to avoid pork products due to religious dietary practices; on 10/13/25, staff purchased "pork fried rice" for Individual #1; on 10/27/25, staff purchased "pork fried rice" and "pork eggroll" for Individual #1. | An individual shall be treated with dignity and respect. | The program director reviewed the receipts dated 10/13/25 and 10/27/25 and confirmed that pork items were purchased for Individual #1 despite documented dietary restrictions related to religious practice. Staff involved were immediately counseled and reminded that serving prohibited foods violates the individual's rights, dignity, and personal preferences.
All team members reviewed Individual #1's annual assessment and dietary plan to reinforce the individual's cultural and religious dietary needs. Staff were instructed to confirm dietary restrictions before making any food purchases.
A review of all individuals' dietary instructions and recent food purchase receipts was completed to ensure no similar violations occurred. No additional concerns were identified.
See attached #6. |
12/12/2025
| Implemented |
| 6400.181(f) | Individual #1's Initial Assessment was completed 07/07/25 and the Individual Support Plan (ISP) team meeting was held on 11/18/25, there is no record that the Assessment was sent to Individual #1's Supports Coordinator or Guardian. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The program specialist reviewed the record and confirmed that the initial assessment dated 07/07/25 was sent to the Supports Coordinator and Guardian on 07/09/25; however, this distribution occurred past the required 30-day deadline prior to the ISP meeting held on 11/18/25.
A review of all individuals' assessment distribution timelines was completed to ensure compliance with regulatory deadlines. Any cases lacking timely distribution or documentation were corrected by resending assessments and obtaining written confirmation.
Staff responsible for preparing and sending assessments were counseled on the late submission and reminded of the requirement to meet all regulatory timelines and to document distribution promptly.
see attached #5 |
12/12/2025
| Implemented |
| 6400.186 | The current Individual Support Plan and Annual Assessment state that Individual #1 should not consume "pork products", however, staff purchased pork products for the individual's consumption. | The home shall implement the individual plan, including revisions. | The program director reviewed the receipts dated 10/13/25 and 10/27/25 and confirmed that pork products were purchased for Individual #1 despite the ISP and annual assessment clearly stating that they are not to consume pork products. Staff involved were counseled immediately and informed that failure to follow the ISP is a violation of regulatory requirements and person-centered planning standards.
Staff were re-educated on Individual #1's dietary restrictions, and the ISP and Assessment were reviewed with the entire team to ensure understanding. A copy of the individual's dietary instructions was placed in the kitchen and in the To-Go Binder for easy reference.
A review of all individuals' ISP instructions related to diet, religious preferences, and personal choices was completed. Staff received clarification and corrective feedback where needed, and no additional violations were found.
See attached #7. |
12/12/2025
| Implemented |