| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | An individual's funds shall be used for the individual's benefit. On 12/06/2025, Individual #1's funds were used to purchase a sheet set for $21.97 and bedsheets for $39.84 at Walmart. On 4/14/2025, Individual #1's funds were used to purchase a 5-piece bed set for $52.00 and a bed in a bag for $52.94. These purchases are for sheets and bedding and should be provided by the Provider as part of room and board. | Individual funds and property shall be used for the individual's benefit. | Provider reimbursed individual for items covered by Room and Board.-please see attached items and copy of check. A meeting was held with his Supports Coordinator to include information in the ISP as to this individual wanting to purchase items already paid for by the provider and available in the home from an education standpoint to staff and the individual. Provider will be sure to pay for items covered by Room and Board. |
01/07/2026
| Implemented |
| 6400.62(c) | Poisonous materials shall be stored in their original labeled container. An unlabeled plastic spray bottle filled with an unknown cleaning liquid was found stored with other cleaning products at the time of the inspection. | Poisonous materials shall be stored in their original, labeled containers. | Residential Director removed the unlabeled plastic bottle from the home the day of inspection 12/30/25. Provider agency reeducated Residential Directors and DSP's as to the regulations pertaining to Poisons in the homes specifically to inspect that all labels are secured to the original bottles and that all poisons are retained in their original containers. |
01/06/2026
| Implemented |
| 6400.106 | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. The home has an operable gas fired furnace and there was no documentation that an annual inspection and cleaning was completed. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| Provider had the furnace inspected and cleaned. please see submitted document. |
01/06/2026
| Implemented |
| 6400.144 | Health services that are planned or prescribed for the individual shall be arranged for or provided. Individual #1 had a psychiatric medication review on 4/21/2025 at which time blood work results were reviewed and the recommendation was made for the individual to follow up with their primary care physician. The individual went to their PCP on 6/09/2025 for a sick visit (bronchitis) but there was no documentation that the individual saw their PCP to follow up on blood work results as recommended by the Individual's psychiatric provider. | 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.
| Residential Director had review of bloodwork results by the individual's PCP on 11/19/2025 from 3/2025 and 9/2025 draws.-please see submitted document. There were no health concerns by the Psychiatrist at the 4/2025 appointment but recommendations for regular wellness checks. Agency will be sure to have clearer documentation and follow all recommendation in a timely fashion moving forward. |
01/06/2026
| Implemented |
| 6400.181(c) | The list of persons who participated in the individual plan meeting shall be kept. A copy of the list of persons who participated in the individual plan meeting for Individual #1 was not available in the Individual's record. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | Residential Director obtained the ISP Signature sheet and added to the individual's record.-please see document submitted. |
01/06/2026
| Implemented |
| 6400.165(a) | Prescription medications shall be kept in the original container and shall be labeled with a label issued by the pharmacy. The medication Nayzilam nasal spray 5 mg. prescribed for Individual #1 did not have a full pharmacy label on the individual sprays and was not in the original package. Labels on the individual nasal sprays only listed the name of the individual, and did not contain administration instructions or other information usually included on a pharmacy label. | A prescription medication shall be prescribed in writing by an authorized prescriber. | Residential Director reached out to the prescriber for full administration directions specific to how long the seizure must last before staff should administer the spray.-please see submitted image. |
01/21/2026
| Implemented |
| 6400.165(b) | A prescription order shall be kept current. The December 2025 medication administration record (MAR) for Individual #1 lists two medications, Albuterol 90 mcg. Aer HFA and Ibuprofen 600 mg. tablets, as current medications. Neither medication was found in the home at the time of the inspection, and staff reported that the medications had been discontinued. | A prescription order shall be kept current. | Residential Director secured the DC order from the prescriber.-please see submitted document. |
01/13/2026
| Implemented |
| 6400.165(e) | Changes in medication may only be made in writing by the prescriber. The medications Albuterol 90 mcg. AER HFA and Ibuprofen 600 mg. tablets, were discontinued according to staff in the home but there was no written order of the discontinuation of the medication. | Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received. | Residential Director secured the DC order from the prescriber.-please see submitted document. |
01/13/2026
| Implemented |
| 6400.213(1)(i) | 213(1)xiv The individual record for Individual #1 did not document the following personal information: religious affiliation. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Provider added the information to the Individual's face sheet specific to religious affiliation.-please see document submitted. |
01/02/2026
| Implemented |