| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The vanity top of the larger bathroom sink was soiled with a dry milky substance that surrounded the faucet and could be easily scraped away. The vanity top was cleaned at the time of inspection.
The front surfaces of the kitchen cabinet doors were soiled with what appeared to be dried food and spills. The front surface of the microwave and cabinets above were soiled with what appeared to be a layer of grease and dust on the top edge of the cabinet doors. The surface area surrounding the knobs of the pantry and rear exit doors were soiled with what appeared to be layers fingerprints and a dark substance. The process of cleaning the cabinet surfaces was started at time of inspection. | Clean and sanitary conditions shall be maintained in the home. | On 2/27/25 - All Staff (direct care and management) were retrained on the importance of maintaining clean and sanitary conditions in the home ongoing. all areas within the kitchen were cleaned as well as the bathroom and kitchen cabinets and general area were cleaned on 2/19/25 and 2/20/25. Staff were also trained on the importance of how to clean the bathroom and kitchen appropriately and best products to use. |
03/17/2025
| Implemented |
| 6400.67(a) | (REPEAT VIOATION 3/6/24)
The carpet in Individual #1's bedroom had a heavily soiled path from the bedroom door, through the room and into the walk-in closet that was easily visible in contrast to the light tan of the rest of the carpet. The path was approximately 18-24 inches wide as it extended through the room and closet. | Floors, walls, ceilings and other surfaces shall be in good repair. | On 2/27/25 - All Staff (direct care and management) were retrained on the importance of maintaining clean Floors, walls, ceilings and other surfaces so that they shall be in good repair. On 2/24/25 (DC Carpet care LLC) a carpet cleaner company was hired by the program coordinator to clean the carpet. the carpet was clean and is currently in good repair. staff were trained on 2/27/25 on how to maintain maintenance concerns. |
03/17/2025
| Implemented |
| 6400.68(b) | (REPEAT VIOLATION 3/6/24)
The water temperature in the small bathroom of the home tested at 130° at time of inspection. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | On 2/27/25 - All Staff (direct care and management) were retrained on the importance of maintaining appropriate temperatures within the home since Hot water temperatures in bathtubs and showers may not exceed 120°F. On /27/25 - staff were also trained on the best way to take the water temperature on going and during fire drills and the importance of regulating water temperature for our individuals before baths or any usage of the water. On the day of the inspection, 2/19/25 the temperate was lowered manually and then tested (100 degrees) again on 2/20/25 and it read (119 and then 120) and it was reduced after and read below 120 degrees. Due to the fluctuation in temperature and repeat violation , as a precaution three different plumbers were contacted to further assess the water heater and mixing valve to see if something was wrong with the mixing valve or anything else. After further determination the feedback was that the mixing valve that regulates the temperature of the water, and the water heater needs to be changed. One of the three plumbers were hired and the water heater and mixing valve are scheduled to be replaced and updated on 3/20/25. Since the water heater and mixing valve has not been changed as yet - The water temperature at the home has been checked on a weekly (2/19/25, 2/20/25, 2/26/25, 3/4/25, 3/14/25) basis in order to determine that the temperature is within appropriate range and lowered if needed- during the checks the temperature has been within compliance. |
03/20/2025
| Implemented |
| 6400.80(b) | The lower exterior back wall of the home above the deck was partially covered in a dark green substance that also covered the bottom rail of the porch railing.
Dried vines on the sides of the front steps were grown up and over a lattice and extended into and around a windchime hanging from the roof soffit. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | On 2/27/25 - All Staff (direct care and management) were retrained on the importance of maintaining the outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. on 2/20/25 the vines were removed from around the wind chime and cut back and the dark green substance cleaned, and the home power washed to remove the residue. |
03/17/2025
| Implemented |
| 6400.141(c)(4) | The physical documented as completed on 3/13/23 noted that vision and hearing exams were "not done." There was no additional documentation to illustrate that vision and hearing evaluations had been completed prior to nor after the 3/13/23 exam until the physical documented as completed on 3/18/24 for Individual #1 noted that vision and hearing were normal. Vision and hearing were not evaluated annually as required. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | On 2/27/25 - All Staff (direct care and management) were retrained on the importance of ensuring that the physical examination shall include Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. on 2/27/25 the staff reviewed their role and responsibility as it pertained to the individuals getting an annual physical, what components need to be filled out by the doctor on the form and how to follow up if something is missed and who to report errors to. the 2024 (3/18/24) physical for Indvidual #1 was completed and vison and hearing tested on . |
03/17/2025
| Implemented |
| 6400.142(a) | At time of inspection there was no record of dental care being provided. Documentation of consults with dental providers were noted to have occurred on 6/25/24, 9/17/24, 12/11/24 and 1/6/25. Visit notes indicated that all were consults for completion of work under sedation with no indication that teeth cleaning or checking gums and dentures was completed as required. It was reported that the guardians/parents of Individual #1 complete most appointments and required documentation is not always available to the Provider. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | On 2/27/25 - All Staff (direct care and management) were retrained on the importance of ensuring that An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. on 2/27/25 the staff reviewed their role and responsibility as it pertained to the individuals attending and completing a dental appointment with appropriate paperwork filled out by the doctor on the form and how to follow up if something is missed and who to report errors to. individual #1 completed his dental appointment on 3/12/25 |
03/17/2025
| Implemented |
| 6400.165(b) | On 1/12/25 Individual #1 received a dietary change from the speech pathologist that noted medications are now to be crushed. At the time of inspection on 2/19/25 it was reported that all medications were being crushed. Labels for all medications noted the dosage form but did not indicate that the medication should be crushed. The prescription orders were not kept current. | A prescription order shall be kept current. | On 2/27/25 - All Staff (direct care and management) were retrained on the importance of ensuring that A prescription order shall be kept current to ensure client safety. The pharmacy was contacted about the necessary change's needed for the medication record ( MAR)and medication labels and for the march 2025 mars the appropriate rotation of crushed was added to the MAR and the labels updated to reflect crushed during the month of February and ongoing. |
03/17/2025
| Implemented |
| 6400.165(g) | (REPEAT VIOLATION 3/6/24)
Medication reviews were completed within the required timeframes on 2/23/24, 5/10/24, 8/2/24, 9/25/24 and 12/18/24. Documentation of the medication reviews for all dates did not include any information to identify the medications reviewed, including the necessary dose as required. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | On 2/27/25 - All Staff (direct care and management) were retrained on the importance of ensuring that If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. On 2/27/25 the staff reviewed their role and responsibility as it pertained to the individuals attending and completing a psyche appointment with appropriate paperwork filled out by the doctor on the form including the types of medication being reviewed and how to follow up if something is missed and who to report errors to in order to follow up immediately. |
03/17/2025
| Implemented |
| 6400.166(a)(15) | At time of inspection on 2/19/25 it was noted that all medications were being crushed. The February Medication Administration Record (MAR) for Individual #1 did not indicate the need for the pills to be crushed for any medication listed as administered. Per the Regulatory Compliance Guide "Special precautions" include any specific administration instructions such as: causes drowsiness, take with food, do not take with certain types of other drugs, and so on." Special precautions shall be listed on the MAR as required. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Special precautions, if applicable. | On 2/27/25 - All Staff (direct care and management) were retrained on the importance of ensuring that A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Special precautions, if applicable. The pharmacy was contacted about the necessary change's needed for the medication record (MAR)and medication labels and for the march 2025 mars the appropriate notation of the special precautions and crushed was added to the MAR and the labels updated to reflect crushed during the month of February and ongoing. also the doctor office was contacted to ensure that any medications that could not be crushed was then switched to liquid form and the Valproic Acid 250 Mg/5 Ml Soln is now given as a liquid, starting in February 2025 ( 2/21/25) |
03/17/2025
| Implemented |