| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | On 09/15/25 Individual # 1 ate spaghetti and her blood sugar was measured to be 176. Individual # 1 has a Diabetic Protocol which requires the injection of 1 unit of Novolog if blood sugar is between 150-200. Novolog was not administered as required. Additionally, on 09/14/25, Individual # 1 ate mac and cheese and her blood sugar was measured to be 168. Novolog was not administered as required. In addition, the identified health services citation of 6400.144 demonstrate that he agency failed to provide needed care for Individual #1. On 09/10/25, Individual # 1 ate cheese crackers with bologna on it. Her blood sugar was measured to be 150. Novolog was not administered as required. On 09/09/25 Individual #1 ate yogurt and strawberries and her blood sugar was measured to be 173. Novolog was not administered as required. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | On 10/16, an Incident was filed and an investigation was completed by Executive Director (Ind#1 Neglect Incident). |
10/20/2025
| Accepted |
| 6400.111(a) | The extinguishers in each level of the home are listed as 1-A-10BC instead of 2-A. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | House supervisor contacted Kint corporation and they replaced fire extinguishers on all levels of the home with 2-A extinguishers on 10/17/25 (Kint Co receipt Attachment). |
12/01/2025
| Accepted |
| 6400.111(c) | The fire extinguisher in the kitchen was a 1A10BC instead of the required 2A10BC. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | House supervisor contacted Kint corporation and they replaced the kitchen fire extinguisher with 2-A10BC extinguishers on 10/17/25 (Kint Co receipt Attachment). |
12/01/2025
| Accepted |
| 6400.112(c) | The fire drill records for the home do not include problems encountered for any drill completed. | 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. | CEO updated fire drill record on 10/16/2025 to include a section titled "problems encountered" and informed all Residential team members on the same date of the change and how to complete the form (Fire Drill Attachment 1). A fire drill will be completed with the new form by 10/30/25 (Fire Drill Attachment 3). |
10/30/2025
| Accepted |
| 6400.113(a) | Individual # 1's date of admission was 02/06/25. Individual # 1 did not receive fire safety training in general fire safety upon initial admission. | 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. | House supervisors and Program Specialist will be re-trained on initial admission procedures for new individuals to include fire safety training by 11/30/25. |
11/30/2025
| Submitted |
| 6400.143(a) | Individual # 1 has a history of medical appointment refusals. continued attempts to train the individual about the need for health care are not documented in the individual's record. Individual # 1 is diagnosed with Diabetes which requires insulin. Individual # 1 refused NOVOLOG injections on 09/09, 10, 11, 12, 13, 16, 17, 18, 19, 21, 25/25. There is no documentation of continued attempts to train the individual about the need for health care. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | · House supervisor developed a form to track blood sugar, food, refusal of insulin, and whether ongoing education was provided on 10/17/25 and trained team members on 10/20/25. Form implemented with team on 10/22/25. (Ind#1 blood sugar tracking Attachment, Country Club team meeting 10-20-25 Attachment).
· CEO developed a medical appointment refusal form by 10/24/25, which includes education provided to the individual regarding the need for health care
· House supervisors and Program Specialist trained on medical reporting forms on 10/24/2025 (Medical Form Training 10-24-25 Attachment) |
11/15/2025
| Accepted |
| 6400.144 | On 05/01/25, Individual # 1's psychiatric medication review reads" consultation with primary care physician is recommended to discuss the possibility of reducing medication load." The recommended consultation did not occur.
On 09/28/25 between 8pm to 12 AM, Individual # 1 ate spaghetti, but no Blood Sugar was taken as per the service note and MAR. On 09/18/25, Individual # 1 ate Spaghetti at 3 pm but no BS was taken. On 09/17/25, Individual # 1 ate crackers and cheese but no BS was taken. On 09/16/25, Individual # 1 ate spaghetti and cheese wiz but no BS was taken. On 09/15/25, Individual # 1 ate spaghetti and watermelon for supper, but no BS was taken. On 09/13/25, Individual # 1 ate spaghetti after 6pm, but no BS was taken. On 09/12/25, Individual # 1 ate two bananas at 5:30 am. No BS was taken. On 09/11/25, Individual # 1 ate sliced cheese and bologna. No BS was taken.
The Diabetic Protocol last updated 10/08/25 reads "Lantus-5 Units once daily at 10am. Hold for blood sugar lower than 150", however the MAR reads "Lantus Solstar 100 units, Inject 10 units under the skin once daily. Hold for sugars below 100". On 09/25-30, there is no documentation in the service notes or MAR that Blood sugars are checked prior to administration of Lantus.
A service note from 09/20/25 indicates that Individual # 1 ate lasagna, but does not indicate the time of eating. The Diabetic Protocol requires blood sugar monitoring up to one hour after eating with Doses separated by 4 hours. The blood sugar level was taken at 11:30pm. Individual # 1 has a history of eating meals at inconsistent times, however, the meal times are not monitored by the agency to ensure that the Diabetic Protocol is being implemented. | 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.
| · House supervisor developed a form to track blood sugar, food, refusal of insulin, and whether ongoing education was provided on 10/17/25 and trained team members on 10/20/25. Form implemented with team on 10/22/25. (Ind#1 blood sugar tracking Attachment, Country Club team meeting 10-20-25 Attachment)
· House supervisor contacted PCP to schedule a review of medication with PCP and appointment is scheduled for 10/30/25 at 2:45pm. |
11/01/2025
| Accepted |
| 6400.151(a) | Staff #3's date of hire is 06/30/25. Staff # 3 did not receive a physical exam until 07/31/25 | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | CEO notified Residential Management of regulatory standard that staff physical exam must occur prior to hire date on 10/27/25. |
11/15/2025
| Accepted |
| 6400.151(c)(2) | Staff #5's physical examination does not include certification of Tuberculin skin testing. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant, or certified nurse practitioner. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | CEO updated staff physical exam form to indicate lab report attachment for TB testing is required rather than documenting on the physical exam form on 10/27/25. |
11/15/2025
| Accepted |
| 6400.181(e)(7) | Individual # 1's assessment dated 04/08/25 does not identify the ability to sense heat sources. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | Program Specialist updated assessment to include information regarding the ability to sense heat sources on 10/28/25 (Ind#1 Assessment 10-25 Attachment). |
10/28/2025
| Accepted |
| 6400.181(e)(12) | Individual # 1's assessment dated 04/08/25 does not include recommendations for specific areas of training, programming, and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Program Specialist updated assessment to include recommendations for specific areas of training, programming and services on 10/28/25 (Ind#1 Assessment 10-25 Attachment). |
10/28/2025
| Accepted |
| 6400.181(e)(13)(ii) | Individual # 1's assessment dated 04/08/25 does not include the utilization of a wheelchair for long distances. This information is listed as part of the ISP. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | Program Specialist updated assessment to include information regarding the need to utilize a wheelchair for long distances on 10/28/25 (Ind#1 Assessment 10-25 Attachment). |
10/28/2025
| Accepted |
| 6400.211(b)(3) | Individual # 1's demographic/emergency information form does not identify the person who is able to provide emergency medical consent. | Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.
| House Supervisor updated demographic emergency medical consent information for JH on 10/27/25 (Ind#1 Face Sheet 10-25 Attachment). |
10/27/2025
| Accepted |
| 6400.34(a) | Individual # 1 was admitted to the program on 02/06/25 but was not informed of her rights upon admission. Additionally, the rights form does not include 32r1, 32r2, 32r3, 32r4, 32r5, 32s1, 32s2, 32s3, 32v, 33a and 33b. | 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. | Executive Director updated individual rights form to include 32r1-5, 32s1-3, 32v, 33a-b. Updated Individual rights form was reviewed with individuals in residential program and signatures were obtained by 10/24/25 (Ind#1 Individual Rights Update 10-25) |
11/30/2025
| Accepted |
| 6400.166(a)(7) | Individual # 1's pre-packaged medications of Ziprasidone and Vitamin B1 for October 2025, does not have the dose of medication | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | House supervisor will change current pharmacy provider to local pharmacy who will integrate with current electronic Medication Administration Record (eMAR) system by 10/30/25. House Supervisor upon receiving new medication packets or bottles will ensure that the dosage of medication is on the package or bottle. |
11/21/2025
| Accepted |
| 6400.166(a)(8) | Individual # 1's pre-packaged medications of Ziprasidone and Vitamin B1 for October 2025, does not have the route of administration. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | House supervisor will change current pharmacy provider to local pharmacy who will integrate with current electronic Medication Administration Record (eMAR) system by 10/30/25. House Supervisor upon receiving new medication packets or bottles will ensure that the route of administration of medication is on the package or bottle. |
11/21/2025
| Accepted |
| 6400.166(a)(9) | Individual # 1's pre-packaged medications of Ziprasidone and Vitamin B1 for October 2025, does not have the frequency of administration. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | House supervisor will change current pharmacy provider to local pharmacy who will integrate with current electronic Medication Administration Record (eMAR) system by 10/30/25. House Supervisor upon receiving new medication packets or bottles will ensure that the frequency of administration is on the package or bottle. |
11/21/2025
| Accepted |
| 6400.166(a)(10) | Individual # 1's pre-packaged medications of Ziprasidone and Vitamin B1 for October 2025, does not have the administration times. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | House supervisor will change current pharmacy provider to local pharmacy who will integrate with current electronic Medication Administration Record (eMAR) system by 10/30/25. House Supervisor upon receiving new medication packets or bottles will ensure that the administration times of medication is on the package or bottle. |
11/21/2025
| Accepted |
| 6400.166(a)(11) | Individual # 1's pre-packaged medications of Ziprasidone and Vitamin B1 for October 2025, does not have the diagnosis or purpose for the medication. | 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. | House supervisor will change current pharmacy provider to local pharmacy who will integrate with current electronic Medication Administration Record (eMAR) system by 10/30/25. |
11/21/2025
| Accepted |
| 6400.166(a)(12) | Individual # 1's pre-packaged medications of Ziprasidone and Vitamin B1 for October 2025, does not have the date and time of medication administration. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration. | House supervisor will change current pharmacy provider to local pharmacy who will integrate with current electronic Medication Administration Record (eMAR) system by 10/30/25. House Supervisor upon receiving new medication packets or bottles will ensure that the date and time of administration of medication is on the package or bottle. |
11/21/2025
| Accepted |
| 6400.166(a)(12) | Individual # 1's Creon 6000-19000 units of medication is listed to be taken at 10am, 6pm, and 9pm on the MAR, however, the medication label reads it is to be taken at 9am, 5pm and 9pm. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration. | House supervisor contacted doctor and pharmacy multiple times to confirm medication times. New label was obtained and added to current medication on 10/30/25 (Ind#1 medication label Attachment). Current medication bottle and eMAR times match for medication administration. House supervisor contacted providers to change current pharmacy provider to a local pharmacy that will integrate with current electronic Medication Administration Record (eMAR) system by 10/30/25. |
11/30/2025
| Accepted |
| 6400.181(f) | Individual # 1's Assessment was completed on 04/08/25. There is no documentation of the assessment being sent to plan team members at least 30 days prior to the ISP meeting which occurred on 06/11/25. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | CEO re-trained Program Specialist on regulatory requirement to document that assessment was sent to team members at least 30 days prior to ISP meeting on 10/28/25 (PS Training Signature 10-28-25 Attachment). |
10/28/2025
| Accepted |
| 6400.195(c)(4) | Individual # 1's behavior support plan does not include target date to achieve the outcome for the target behaviors of Refusing, Oppositional and Uncleanliness. | The behavior support component of the individual plan shall include: A target date to achieve the outcome. | Behavior Consultant updated Behavior Support Plan to include target dates for goals and objectives on 10/24/25 (Ind#1 BSP 5-25 Attachment) |
10/27/2025
| Accepted |
| 6400.213(1)(i) | Regulation # 213 1ii- Individual # 1's demographic/emergency information form does not include identifying marks. The space is left blank. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | ED updated JH demographics form to include identifying marks on 10/25/25 (Ind#1 Face Sheet 10-25 Attachment). |
10/27/2025
| Accepted |