| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | On 9/25/2025, the provider agency used Individual #1's personal funds to purchase three boxes of Vinyl Powder-Free Gloves for $2.55 per box, totaling $7.65. Staff interviews revealed that Individual #1 does not assist in their own personal care and would not need to utilize the gloves. | Individual funds and property shall be used for the individual's benefit. | Individual #1 has been reimbursed for the cost of the gloves, $7.65. In the future her funds will not be used to cover the cost of items covered under the room and board costs as outlined in 6100.684, specifically 6100.684.d10 incontinence products. Individual #1's funds will be used for items she needs or desires which are not covered under 6100.684. |
12/23/2025
| Implemented |
| 6400.62(a) | On 10/31/2025 at 10:13 AM, there was a steel shackle padlock very loosely fastened onto the handles of the cabinet, under the sink in the kitchen of the home, rendering the cabinet unlocked and accessible as the doors were able to be opened approximately six inches. The cabinet contained spray bottles of Windex and Orange Glo and containers of Pine-Sol and Member's Mark Dishwasher Pods. At 10:25 AM, a package of Cascade Dishwasher Pods and a bottle of Cascade Power Dry Rinse Aid was unlocked and accessible in the cabinet under the sink in the laundry room on the first floor of the home. At 10:58 AM, a spray bottle of Medline Remedy Cleaning Body Lotion with instructions to contact Poison Control if ingested was unlocked and accessible in a cabinet in the kitchen of the home. Individual #1's individual support plan, last updated 10/29/2025, reads, "[Individual #1] requires close proximity supports when in the vicinity of any poisonous substance because [Individual #1] is unable to read. These substances are contained in a locked cupboard at [their] residence and older adult daily-living center." | Poisonous materials shall be kept locked or made inaccessible to individuals. | A more secure lock has been placed on the cabinet under the sink in the kitchen as well as the cabinet under the sink in the laundry area. The locks have been applied so that the cabinets cannot be opened with the locks in place and any items in the cabinet, especially chemicals removed. |
12/23/2025
| Implemented |
| 6400.64(a) | On 10/31/2025 at 10:17 AM, the bottom of the oven was covered in thick black residue and burnt food remnants. At 10:25 AM, there was stagnant water and dark spots of what appeared to be mold, from a leaking pipe under the sink in the laundry room, on the first floor of the home. | Clean and sanitary conditions shall be maintained in the home. | The oven has been thoroughly cleaned, as well as the entire sink in the laundry area. All other appliances and plumbing fixtures in the home were inspected and cleaned as well. |
12/23/2025
| Implemented |
| 6400.67(a) | On 10/31/2025 at 10:25 AM, there was a pipe leaking into the cabinet under the sink in the laundry room on the first floor of the home. | Floors, walls, ceilings and other surfaces shall be in good repair. | The sink in the laundry area has been assessed by maintenance staff and determined that a fitting was broken. The broken fitting has been replaced, and the leak has ceased. |
12/23/2025
| Implemented |
| 6400.67(b) | On 10/31/2025 at 10:39 AM, a four-inch by two-inch section of the paneled floor outside Individual #2's bedroom was loose and was dented inward when stepped on posing a tripping hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The four-inch by two-inch section of the paneled floor outside Individual #2's bedroom has been replaced with similar flooring and the edges sanded to prevent any lifted areas which would create tripping hazards. |
12/23/2025
| Implemented |
| 6400.72(a) | On 10/31/2025 at 10:16 AM, there was no screen in the operable window in the bathroom, near the kitchen on the first floor of the home. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Materials have been ordered to construct a screen for the bathroom window since the original screen is no longer available. |
12/23/2025
| Implemented |
| 6400.80(b) | On 10/31/2025 at 10:52 AM, the cement paver directly outside the exit in the basement of the home, was protruding upward approximately one and a half inches from the second concrete paver, posing a tripping hazard. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The maintenance staff raised the cement paver, putting gravel under the paver to prevent future sinking into the dirt and making sure the pavers were then level. In addition, the dirt area next to the cement pavers has been smoothed out and seeded with grass to slow the water flow around the pavers and prevent mud and erosion, allowing the pavers to become unlevel again. |
12/23/2025
| Implemented |
| 6400.114(b) | The provider agency's smoking policy prohibits smoking inside the home while individuals are present. Staff interviews revealed that staff have been utilizing a lit cigarette inside the home and waving it in front of the smoke detectors to set off the fire alarms for monthly fire drills, while the individuals are home. | Written smoking safety procedures shall be followed. | The staff who has been responsible for conducting most of the fire drills at this location was trained on 11/5/2025 how to appropriately set off the fire alarm for a drill. A drill was conducted on this day using the appropriate method, pushing and holding the button in the center of the smoke detector. The alarm functioned properly and activated the interconnected fire alarms in the residence. |
12/23/2025
| Implemented |
| 6400.141(c)(8) | As of 9/26/2024, Individual #1 is recommended to have mammograms completed annually. Individual #1's most recent mammogram was completed on 9/26/2024. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | Individual #1 is scheduled for a mammogram on 2/12/2026, the soonest available appointment for the specific diagnostic imaging recommended for her. She will continue to receive annual mammograms until her physician determines she is clear and they are no longer necessary. |
12/23/2025
| Implemented |
| 6400.216(a) | On 10/31/2025 at 11:35 AM, a binder that contained the personal demographic information and Individual Support Plans of Individual #1, Individual #2, Individual #3, and other individuals living in the provider agency's other homes, was unlocked and unattended on top of the microwave in the kitchen of the home. | An individual's records shall be kept locked when unattended.
| The binder containing the personal information and Individual Support Plans has been properly secured in the office, which is kept locked. |
12/23/2025
| Implemented |
| 6400.32(r)(1) | On 10/31/2025 at 10:20 AM, there was a turn locking mechanism on the inside with a pinhole locking mechanism on the outside of the door leading to Individual #3's bedroom. Individual #3 has not been provided with a designated mechanism to lock and unlock the door independently. Staff interviews also revealed that Individual #3 is not physically able to utilize this locking mechanism independently. At 10:22 AM, there was a turn locking mechanism on the inside with a pinhole locking mechanism on the outside of the door leading to Individual #1's bedroom. Individual #1 has not been provided with a designated mechanism to lock and unlock the door independently. At 10:30 AM, there was a turn locking mechanism on the inside with a pinhole locking mechanism on the outside of the door leading to Individual #2's bedroom. Individual #2 has not been provided with a designated mechanism to lock and unlock the door independently. | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | The locks for the individuals in this residence have been removed and replaced with regular bedroom doorknobs. Each individual's record contains a door lock form which is reviewed annually and all three of these individuals have communicated that they do not want a lock on their bedroom door, and as stated Individual #3 is physically unable to manipulate a lock or place herself next to the door to manipulate any type of locking device. |
12/23/2025
| Implemented |
| 6400.32(r)(5) | On 10/31/2025 at 10:20 AM, there was a turn locking mechanism on the inside with a pinhole locking mechanism on the outside of the door leading to Individual #3's bedroom. Staff did not have a designated mechanism to unlock the bedroom door in case of an emergency. At 10:22 AM, there was a turn locking mechanism on the inside with a pinhole locking mechanism on the outside of the door leading to Individual #1's bedroom. Staff did not have a designated mechanism to unlock the bedroom door in case of an emergency. At 10:30 AM, there was a turn locking mechanism on the inside with a pinhole locking mechanism on the outside of the door leading to Individual #2's bedroom. Staff did not have a designated mechanism to unlock the bedroom door in case of an emergency. | Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door. | For Individuals #1, #2, and #3, the door locks have been removed from their bedroom doors and replaced with regular doorknobs. They have been informed of their right to have a locking door and either chose not to have a lock or would not be able to independently operate any type of locking mechanism. There are currently no locking bedroom doors in the residence. |
12/23/2025
| Implemented |
| 6400.34(a) | Individual #1 was informed of and explained individual rights on 9/09/2024 and then again on 10/13/2025. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Individual #1's individual rights were reviewed and signed on 10/13/2025 which was the date of her annual meeting. The individual rights are normally reviewed and signed at the annual review meeting. Her previous annual was 11/11/2024. It is unclear why the individual rights were dated for September 2024 and it was an oversight that they were not reviewed again in September 2025. In the future, it will continue to be reviewed during the annual review meeting to remain in compliance. |
11/26/2025
| Implemented |
| 6400.166(a)(5) | Individual #1's October 2025 medication administration record did not include the strength of Acetaminophen 500MG Tablets. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | Individual #1's medication administration record has been corrected to include the strength of the Acetaminophen. The other medications and treatments on the medication administration record were reviewed to ensure the strength is included for each medication and treatment. |
11/25/2025
| Implemented |
| 6400.166(a)(7) | Individual #1 is prescribed Tussin DM with instructions to, "Give 10MLs by mouth as needed for cough/congestion." Individual #1's October 2025 medication administration record documents, "Give 5ML-10MLs by mouth as needed for cough/congestion." | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | Individual #1's medication administration record has been corrected to include the correct dose of the Tussin. The other medications and treatments on the medication administration record were reviewed to ensure the dose is correct for each medication and treatment. |
11/25/2025
| Implemented |
| 6400.166(a)(11) | Individual #1's October 2025 medication administration record did not include a diagnosis or purpose for Vitamin D. | 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 Vitamin D prescription for Individual #1 was verified with the order and the diagnosis or purpose was written on the medication administration record. All other medications on the medication administration record were reviewed to ensure the information matched and the diagnosis was listed. |
11/25/2025
| Implemented |
| 6400.166(b) | Individual #1's prescribed medication, Metoprolol, was not initialed as administered at 7:00 AM and 7:00 PM on 10/29/2025. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The error for Individual #1 occurred on 10/29/2025 and therefore this particular error cannot be corrected at this time. |
11/25/2025
| Implemented |
| 6400.182(c) | Individual #1's assessment, completed 11/29/2024, states that Individual #1 is independent with poisons. Individual #1's individual support plan, last updated 10/29/2025, documents, "[Individual #1] requires close proximity supports when in the vicinity of any poisonous substance because [Individual #1] is unable to read. These substances are contained in a locked cupboard at [their] residence and older adult daily-living center." Additionally, Individual #1's individual support plan documents, "[Individual #1] had [their] last mammogram on 9/26/24 and is now since exempt from mammogram's and routine gyn per physician." The results of Individual #1's 9/26/2024 mammogram results recommend that it is completed annually. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Individual #1's current assessment, dated 11/17/2025, has been updated to correctly reflect her awareness and handling of poisons, "Patricia independently demonstrates knowledge of non-edibles and is able to identify the chemicals by the appearance of the bottle since she does not read but due to limited physical ability, specifically the use of one arm/hand and poor strength in the good arm/hand she would not be able to safely handle the chemicals independently. For this reason, and the safety of her housemates, the chemicals are kept securely locked." This information matches the information in her Individual Support Plan. The Supports Coordinator has been contacted and the Individual Support Plan has been updated to reflect the information regarding her annual mammograms which will continue until recommended otherwise by her physician. Her current Individual Support Plan reads as follows, "PATTY HAD HER LAST MAMMOGRAM ON 9/26/24 AND WILL RETURN FOR ANNUAL APPOINTMENTS UNTIL FURTHER NOTICE." |
11/26/2025
| Implemented |