| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.24 | The Room and Board Residency Agreement for Individual #1 was not completed. The amount of the rental payment is not indicated on agreement. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | The current Room and Board Agreement was updated to reflect the amount currently paid monthly. The terms of the agreement did not change. |
07/15/2025
| Implemented |
| 6400.46(b) | Adherence to the annual requirement for fire safety training was not met by the following Staff Members:
Staff Member #1 completed fire safety training on 5/30/24 and then on 6/3/25.
Staff Member #2 completed fire safety training on 5/30/24 and then on 6/14/25.
Staff Member #5 completed fire safety training on 5/30/24 and then on 6/3/25. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Staff Members #1 and #2 completed their fire safety training by 6/30/25; therefore, the violation had been corrected. |
07/31/2025
| Implemented |
| 6400.166(a)(11) | The MAR for Individual #1has multiple medications including Lisinopril 2.5mg tablet and Ferrous Sulfate 325mg tablet that does not state the purpose for the medications. | 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. | The agency nurse contacted the prescribing physician for the medications for Individual #1 to update the order to include the diagnosis. The prescribing physician didn't provide the diagnosis to the pharmacy in time for the printing of the August MARs. The nurse manually wrote the diagnosis for July and August 2025. Beginning in September 2025, the diagnosis will be printed on the MARs. |
07/31/2025
| Implemented |