| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(c) | The agency's self-assessment completed for this home between 6/2/25 to 7/4/25, did not provide a written summary of corrections made for any of the following 6400 regulation items identified as violations: .64a; .71; .72a; .77b; .82g; .112e; .163d; .163f; .165f; .165g; .168a; .181b; .181e1; .181e2; .181e3ii; .181e6; .181e12; and .181f. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| Immediate Action: The Agency will re-conduct an LIS immediately, ensuring all sections that have been marked as (V) have an attached POC and completion date by 8.24.25. |
08/24/2025
| Implemented |
| 6400.141(c)(3) | Individual #1's last tetanus-diphtheria immunization was received on 5/21/13. | 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. | Actions immediately taken: What do we do right now?
¿ The person previously responsible for ensuring the immunizations were conducted in accordance with Chapter 6400 have been relieved of their duties permanently.
¿ After notification, during the inspection. The Individual received a TDAP immunization at the pharmacy. This was completed on: July 11th 2025.
¿ Due to this violation. A comprehensive review of all residential Individuals immunization records was conducted.
¿ All individuals found to be non-compliant were directed to receive TDAP immunizations.
¿ All individuals achieved compliance status as of July 18, 2025. |
08/20/2025
| Implemented |
| 6400.141(c)(14) | Individual #1's current physical examination, completed on 11/4/24, did not address medical information pertinent to diagnosis and treatment in case of an emergency, as the corresponding field was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Actions immediately taken: What do we do right now?
¿ The person previously responsible for ensuring the Physical examinations were completed in accordance with Chapter 6400 have been relieved of their duties permanently.
¿ June 10th 2025. Individual # 1¿s physical examination was returned to their PCP for completion. We included an Attestation for the MD to sign. The MD signed the Attestation but didn¿t sign the updated form. The attestation stated the information was addressed during the visit. 6400.141 (14). * Please see enclosed.
¿ To ensure compliance with Chapter 6400.141 (C ) (14) Individual #1 has been scheduled for a physical follow- up appointment on August 8th at 10:00AM. * Please see attached the Therap calendar for this appointment.
¿ The Nurse Specialist is currently in the process of reviewing all individuals' physical examination records. These reviews will be completed on or before August 1st 2025. To identify any similar documentation gaps.
¿ The team leaders will schedule identified follow-up appointments by Aug 5th for any individual documentation requiring updated or complete physical examinations. New physicals will be scheduled immediately for any individual with incomplete paperwork.
¿ Documentation of reviews will be listed on the LIS for all physical examinations. |
08/15/2025
| Implemented |
| 6400.144 | The attending physician who had conducted Individual #1's current physical examination on 11/4/24 provided recommendations for Individual #1 to have follow-up blood work completed within six months of this physical examination. However, Individual #1's content of records did not include documentation that these recommended health services for follow-up blood work had ever been completed. | 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.
| Actions immediately taken: What do we do right now?
¿ The person previously responsible for ensuring the Health Service follow-up were conducted in accordance with Chapter 6400 have been relieved of their duties permanently.
¿ Individual #1¿s blood work was completed on Wednesday, July 16th at 8:00AM
¿ All Medical Appointment record forms will be reviewed including ( Health service follow-up) on or before August 15th 2025.
¿ A LIS of the reviews will be kept. |
08/15/2025
| Implemented |
| 6400.32(r)(1) | On 7/9/25, Individual #1's bedroom door was equipped with a privacy lock that had a push-pinhole access point on the exterior. This locking assembly does not provide Individual #1 with a unique mechanism in which to lock and unlock their bedroom door. | 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. | Immediate Action: Operations Director met with a contractor on 7.21.25. to initiate work order for locking mechanisms that allow for more security and privacy and that better align with 6400.32r1. |
08/01/2025
| Implemented |
| 6400.182(b) | Individual #1's date-of-admission is 10/23/24. Their initial assessment, completed on 12/20/24, was neither sent to plan team members until 6/30/25, nor had there been an Individual Service Plan Meeting held within 90 days of Individual's admission or since in order to develop an Individual Service Plan based on this initial assessment. | The initial individual plan shall be developed based on the individual assessment within 90 days of the individual's date of admission to the home. | Actions immediately taken: What do we do right now?
¿ The person previously responsible for ensuring the Initial plan meetings were conducted in accordance with Chapter 6400 have been relieved of their duties permanently.
¿ An audit of Individual # 1 binder yielded a copy of the ISP meeting that the NFHCS staff attended the meeting on Nov 6th 2024. Please see attached ISP meeting sign in sheet.
¿ A complete review of all of the ISP meeting sheets will be reviewed prior to August 13th 2025. By the Program Specialist.
¿ Documentation of the reviews will be recorded on the LIS once completed. |
08/15/2025
| Implemented |