| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.77(b) | At the time of the inspection the first aid kit did not contain gauze tape. Once it was noticed the gauze tape was missing, staff did go to their vehicle to obtain gauze tape to replace in the home's first aid kit. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | Provider staff Residential Director placed the tape in the first aid kit at the time of the inspection. |
01/29/2026
| Implemented |
| 6400.80(a) | Outside walkways shall be free from snow, ice and other hazards. At the time of the inspection the front sidewalks that led to the walkway to the home was covered in ice and snow. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | Provider agency staff cleared all walkways and driveways around the home from snow and ice.
Provider agency reeducated Residential Directors and DSP's as to the regulations pertaining to Outside Walkways at all times. See submitted document. |
12/31/2025
| Implemented |
| 6400.141(c)(4) | Individual was seen at PCP on 1.31.25 to establish care, however the physical did not include a hearing and vision screening. That area of the physical was checked "no" and N/A was written. In addition, the individual was scheduled at the eye Dr on several occasions since admission all of which she refused. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | The Medical Provider circled NO initially then crossed out and initialed cross out and circled YES. please see submitted document. The individual did keep her scheduled appointment for Vision services on 1/16/26 and refused the prescribed glasses. Provider agency will continue to work with this individual and her team as to the refusal of various therapies, medical, and psychiatric care appointments. -please see submitted documents. |
01/16/2026
| Implemented |
| 6400.142(f) | Individual shall have a dental hygiene plan written annually. The individual dental hygiene plan was dated 1.8.25 however the form is generic to all individuals and does not describe the personal needs of each individual. The dental hygiene plan shall identify the specific need of each individual in the area of dental hygiene. The plan did not provide a clear explanation of this individual's ability in this area. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | Provider Residential Director reported that this individual is independent in Dental hygiene. After reviewing the ISP it notes independence as well. Provider agency has a past practice of creating a Dental Hygiene Plan for every individual in care. Based on this individual's independence we have now removed the Dental Hygiene Plan. |
01/02/2026
| Implemented |
| 6400.143(a) | Individual was seen for left leg pain on 10.27.25 and was referred to PT and she refused PT on 12.2.25. If an individual refuses medical treatment the refusal and continued attempts to train the individual about the need for the health care shall be documented. | 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. | Provider Residential Director reached out to the PT provider to ensure that there was not an appointment previous to the 12/2/2025 that was refused. The provider confirmed that there was not a previous appointment for PT.-please see the refusal document that was signed on 12/2/25. This individual has noted in her ISP that she often refuses various therapies, medical, dental and psychiatric care appointments. This is her first community home setting and she is very independent at age 61. |
01/02/2026
| Implemented |
| 6400.144 | Individual was seen at the Dr for nail biting on 6.12.25, at this time it was recommended that this individual be seen by psychotherapy to help with nail biting. There was no documentation that psychotherapy had been established. The documentation provided were med reviews. Psychotherapy is more collaborative treatment to help change unhealthy behaviors and thoughts by improving mental wellness and helping increase healthier coping skills, this often includes a talk therapist. Med reviews are to address medication issues, psychotherapy is an additional treatment. | 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.
| Provider Residential Director discussed Psychotherapy with this individual who was not interested in the service at that time. Residential Director readdressed this with the individual but did not make an appointment or document the refusal. The individual has now signed a document with regard to refusing Psychotherapy.-please see submitted document |
01/29/2026
| Implemented |