| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | On 11/25/2025 at 11:06 AM, the upstairs bathtub handle was no longer secured to the wall and the area on the wall where the handle had been attached was covered in, what appeared to be, a rust-like substance. The bathtub spicket as well as the overflow cover were corroding and were also covered in a rust-like substance. | Floors, walls, ceilings and other surfaces shall be in good repair. | The Program Director, Quality Assurance Associate, Program Specialists, Program Managers, and the Facilities Director were retrained on the regulation. The agency has been in the process of receiving quotes from companies to replace the tub and components. A contractor was identified and the work will be begin as soon as 12/18/25 but completed by 12/31/25. |
12/31/2025
| Implemented |
| 6400.72(a) | On 11/25/2025 at 11:00 AM, the screen in the window in Individual #1's bedroom was an accordion-style screen that did not provide a secure seal to prevent against infestation. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | The Facilities Director was retrained on the regulation and that accordion style screens are not permitted. The screen was replaced on 11/26/25. |
11/26/2025
| Implemented |
| 6400.72(b) | On 11/25/2025 at 10:55 AM, the far-left window, facing the front of the home, on the bottom floor had a 1 inch by 1 inch tear in the screen. | Screens, windows and doors shall be in good repair. | The Facilities Director was retrained on the regulation. Screens were replaced on 11/26/25. |
11/26/2025
| Implemented |
| 6400.141(c)(3) | Individual #1's diphtheria, tetanus, and pertussis vaccinations were completed on 6/12/2014 and then again 7/10/2024. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | The Program Director, Quality Assurance Associate, Program Specialists, and Program Managers were retrained on the regulation. It is advised that a person receive an updated TDAP sometime by the 9th year rather than awaiting the 10 year mark. |
12/12/2025
| Implemented |
| 6400.141(c)(4) | Individual #1's vision screenings were completed on 8/26/2024 and then again on 10/17/2025. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | The Program Director, Quality Assurance Associate, Program Specialists, and Program Managers were retrained on the regulation. Vision appointments will be scheduled within 1 year of the last appointment. Program Managers will document any refusals on Therap with any correlating education and counseling, Program Specialists will meet with the individual monthly to provide education and counseling on the importance of attending appointments. This will be documented on the quarterly review.
Providers Plan to Maintain Compliance: Program Managers will document any refusals or reasons for missing appointment on Therap with any correlating education and counseling. Program Specialists will meet with the individual monthly to provide education and counseling on the importance of attending appointments and document on the quarterly review. Program Managers will schedule any annual or necessary follow up appointments with Program Specialist oversite. QA will routinely review records for compliance. |
12/12/2025
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination, completed 7/15/2025, did not include medication information pertinent to diagnosis and treatment in case of an emergency. This section was left blank on the physical examination form. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The Program Director, Quality Assurance Associate, Program Specialists, and Program Managers were retrained on the regulation. Those attending appointments will ensure that the medical office completes forms in their entirety without blanks. |
12/12/2025
| Implemented |
| 6400.169(a) | Direct Service Worker #1 completed their annual medication administration practicum on 9/17/2024. Since this date, Direct Service Worker #1 was observed administering medications on 3/13/2025 and 9/8/2025; however, only one medication administration record review was completed on 6/16/2025. Direct Service Worker #1 did not complete all renewal requirements to be recertified to administer medications on 9/17/2025. Direct Service Worker #1, who is not qualified to administer prescription medications, administered Amlodipine Tab 5 MG with directions to take one tablet by mouth once daily for blood pressure to Individual #1 on 11/1/2025, 11/10/2025, 11/11/2025, 11/20/2025, and 11/21/2025 at 8:00 AM. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | HR has been retrained on the regulation. ABDD is completing a comprehensive retraining on December 16-17, 2025. |
01/30/2026
| Implemented |