| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.77(c) | There was no manual in the first aid kit during the physical site walk through. | A first aid manual shall be kept with the first aid kit. | 1. Field Managers and License Compliance Managers have checked first aid kits in all homes and were found to be in compliance.
2. All staff will be trained on 6400.77(c) and sign off by 9-1-25. |
09/01/2025
| Implemented |
| 6400.112(c) | Fire drills conducted on 09/08/24, 11/11/24, 12/23/24, 01/07/25, 02/14/25, 03/29/25, 04/13/25, 05/05/25 do not include problems encountered. The spaces were left blank. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | 1.License Compliance Manager has reviewed all previous fire drill reports from the past 12 months to ensure compliance. All other homes were found to be in compliance
2.All staff will be trained and Emphasize the importance of complete and accurate documentation, especially the Problems Encountered section and review how to properly complete fire drill form. Staff will be trained by License Compliance Manager and sign off by 9-1-25. |
09/01/2025
| Implemented |
| 6400.144 | (Repeat 12/19/24) Individual # 1 is prescribed PRN medication Acetaminophen 325mg tablets, take two tablets (650 mg) orally 4 times daily as needed for pain or fever. The Acetaminophen medication at the home was 500 mg/capsules instead of 325 mgs. The PRN Acetaminophen cannot be given as prescribed with 500 mg capsules. | 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.
| 1.All medications in all homes were compared to each individuals physicians orders and all were found to have been correct and compliant
2. Next Step Care has created an inventory log (any time medications are delivered by the pharmacy or by the individuals designee staff on shift will immediately compare the medication to the Individuals physician orders and sign off stating each medication is correct and compliant)
3. Staff will be trained on new log and procedure by 9-1-25 |
09/01/2025
| Implemented |