| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(f) | The fire drill records showed for the past year that the provider did not alternate the exit route during fire drills and only used the front door to exit the home. | Alternate exit routes shall be used during fire drills. | Correction ¿ Immediate Cure
WHO:
Residential Director
Regulatory Specialist
House Leads
Staff
Program Specialist
Human Resources Personnel
WHAT:
We need to ensure that the Individuals have practice using all the exit routes in the home.
WHEN:
June 2, 2025 to June 13, 2025
HOW:
A fire drill was held in the home on June 5, 2025, with the Individuals using the back exit. Between June 2, 2025 and June 13, 2025, fire drills were conducted at all the other homes, with alternative exits being used in homes with alternative exits. |
06/30/2025
| Implemented |
| 6400.113(a) | Individual #1's last fire safety training was conducted on 5/10/24, however compliance was not met as there was no May 2025 training completed. | 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. | Correction ¿ Immediate Cure
WHO:
Program Specialist
Residential Director
Regulatory Specialist
House Leads
Human Resources Personnel
WHAT:
We need to ensure that all Individuals attend Fire Safety Training every twelve months.
WHEN:
June 3, 2025
HOW:
The Program Specialist attended the Fire Safety training class held in May 2025, by the outside fire safety expert. As such, she instructed Individual #1 on 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. The same training was conducted for another Individual who was unable to participate in the Fire Safety training. The training was conducted on June 3, 2025. |
06/24/2025
| Implemented |
| 6400.141(c)(10) | The current physical exam did not indicate if individual #1 was free from communicable disease, this section of the form was left blank. | 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. | Correction ¿ Immediate Cure
WHO:
Nurse
Program Specialist
Residential Director
Regulatory Specialist
House Leads
Human Resources Personnel
WHAT:
We need to ensure that each Individual¿s physical form is completed in its entirety, including indicating whether the Individual is free of communicable diseases.
WHEN:
July 2, 2025
HOW:
We returned the physical form to the treating physician to complete the annual physical form in its entirety. We also reviewed the annual physical form for all the Individuals to ensure that any non-complying form is cured. All non-complying physical forms were returned to the treating physician to be completed in its entirety. |
07/02/2025
| Implemented |
| 6400.141(c)(14) | Individual #1's current physical exam did not indicate information pertinent to diagnosis. The section of the form was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Correction ¿ Immediate Cure
WHO:
Nurse
Program Specialist
Residential Director
Regulatory Specialist
House Leads
Human Resources Personnel
WHAT:
We need to ensure that each Individual¿s physical form is completed in its entirety, including providing information pertinent to the Individual¿s diagnosis.
WHEN:
July 2, 2025
HOW:
We returned the physical form to the treating physician to complete the annual physical form in its entirety. We also reviewed the annual physical form for all the Individuals to ensure that any non-complying form is cured. All non-complying physical forms were returned to the treating physician to be completed in its entirety. |
07/02/2025
| Implemented |
| 6400.144 | Individual #1's prescribed PRN Benzonatate 200 mg not found with medications upon review. | 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.
| Note: The PRN medication was not present in the medication box because it was previously discontinued by the prescribing physician. As such, it was taken out of the medication box.
Correction ¿ Immediate Cure
WHO:
Nurse
Program Specialist
Residential Director
Regulatory Specialist
House Leads
Human Resources Personnel
WHAT:
We need to ensure that each Individual¿s electronic medication record correctly represents the Individual¿s current medication. This requires comparing the electronic medication record with the content of the medication box.
WHEN:
July 2, 2025
HOW:
We immediately updated the electronic medication record to show that the PRN has been discontinued, with the discontinuation paperwork attached to the record. We also inspected the electronic medication record for all the Individuals to ensure that the content of the medication box matches the medication listed on the electronic medication record. |
07/02/2025
| Implemented |
| 6400.32(r) | The agency has not updated their client's rights document to include this subsection. This was true for individual #1. | An individual has the right to lock the individual's bedroom door. | Note: All our Individuals are aware that they have the right to lock their bedroom doors. In fact, all our Individuals routinely exercise this right.
Correction ¿ Immediate Cure
WHO:
Program Specialist
Residential Director
Regulatory Specialist
House Leads
Staff
Human Resources Personnel
WHAT:
We need to ensure that each Individual is aware that he/she/they have the right to lock his/her/their bedroom doors. We also need to ensure that we have documentation showing that this right has been discussed with the Individuals.
WHEN:
June 2, 2025 ¿ June 3, 2025
HOW:
We immediately reviewed this right again with Individual #1. We also immediately reviewed the right with all the other Individuals. |
07/02/2025
| Implemented |