| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | On 11/25/2025 at 11:51am, approximately 20 to 25 tiles were missing on the wall behind the toilet in the full bathroom on the second floor of the home. Where the tiles were missing, a rough, unfinished portion of the wall was exposed. | 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. The work was completed on 12/2/25. |
12/02/2025
| Implemented |
| 6400.141(c)(7) | Individual #1's most recent gynecological examination was completed on 12/8/2023. The agency obtained a letter from the individual's physician dated 10/3/2024 indicating a Pap smear was only necessary every three years between the ages of 21 and 29; however, the letter did not defer the annual gynecological examination. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | The Program Director, Quality Assurance Associate, Program Specialists, and Program Managers were retrained on the regulation. If a medical professional recommends no or less frequent examinations, language should include all components of the regulation -- PAP smear, breast examination, and/or gynecological examination. |
12/12/2025
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination, completed 8/8/2025, 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 |
| 6400.144 | Individual #1's psychiatric medication review that was completed on 1/9/2025 indicated the need for a follow-up appointment on 2/5/2025. Individual #1 did not attend this appointment as planned. An incident report was observed in Individual #1's chart that read, "[Individual #1] missed [their] scheduled psych appt 2/5/2025." The agency failed to provide Individual #1 with planned health services. | 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.
| The Program Director, Quality Assurance Associate, Program Specialists, and Program Managers were retrained on the regulation. |
12/12/2025
| Implemented |
| 6400.166(a)(4) | On 1/13/2025, Individual #1 was prescribed Cranberry 600mg with instructions to take 1 capsule by mouth once daily for urinary health. On 11/25/2025 at 12:43pm, it was observed that Individual #1's The November 2025 medication administration record did not include the name of this medication. This medication was omitted entirely from the November 2025 medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | The Program Director, Quality Assurance Associate, Program Specialists, and Program Managers have been retrained on the regulation. The medication was placed on the MAR on 11/25/25. |
11/25/2025
| Implemented |
| 6400.166(a)(5) | On 1/13/2025, Individual #1 was prescribed Cranberry 600mg with instructions to take 1 capsule by mouth once daily for urinary health. On 11/25/2025 at 12:43pm, it was observed that Individual #1's The November 2025 medication administration record did not include the strength of this medication. This medication was omitted entirely from the November 2025 medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | The Program Director, Quality Assurance Associate, Program Specialists, and Program Managers have been retrained on the regulation. The medication was placed on the MAR on 11/25/25. |
11/25/2025
| Implemented |
| 6400.166(a)(6) | On 1/13/2025, Individual #1 was prescribed Cranberry 600mg with instructions to take 1 capsule by mouth once daily for urinary health. On 11/25/2025 at 12:43pm, it was observed that Individual #1's The November 2025 medication administration record did not include the dosage form of this medication. This medication was omitted entirely from the November 2025 medication administration record.
On 11/25/2025 at 11:25am, it was observed that Polyethylene Glycol Powder 3350 NF prescribed to Individual #1 indicated to dissolve the medication in 8 ounces of liquid on the pharmacy issued medication label; however, the November 2025 medication administration record did not include this information about the dosage form of the medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | The Program Director, Quality Assurance Associate, Program Specialists, and Program Managers have been retrained on the regulation. The medication was placed on the MAR on 11/25/25. |
11/25/2025
| Implemented |
| 6400.166(a)(7) | On 1/13/2025, Individual #1 was prescribed Cranberry 600mg with instructions to take 1 capsule by mouth once daily for urinary health. On 11/25/2025 at 12:43pm, it was observed that Individual #1's The November 2025 medication administration record did not include the dose of this medication. This medication was omitted entirely from the November 2025 medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | The Program Director, Quality Assurance Associate, Program Specialists, and Program Managers have been retrained on the regulation. The medication was placed on the MAR on 11/25/25. |
11/25/2025
| Implemented |
| 6400.166(a)(8) | On 1/13/2025, Individual #1 was prescribed Cranberry 600mg with instructions to take 1 capsule by mouth once daily for urinary health. On 11/25/2025 at 12:43pm, it was observed that Individual #1's The November 2025 medication administration record did not include the route of administration for this medication. This medication was omitted entirely from the November 2025 medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | The Program Director, Quality Assurance Associate, Program Specialists, and Program Managers have been retrained on the regulation. The medication was placed on the MAR on 11/25/25. |
11/25/2025
| Implemented |
| 6400.166(a)(9) | On 1/13/2025, Individual #1 was prescribed Cranberry 600mg with instructions to take 1 capsule by mouth once daily for urinary health. On 11/25/2025 at 12:43pm, it was observed that Individual #1's The November 2025 medication administration record did not include the frequency of administration for this medication. This medication was omitted entirely from the November 2025 medication administration record.
On 11/25/2025 at 11:29am, it was observe that Epinephrine Injection 0.3mg prescribed to Individual #1 indicated on the pharmacy issued medication label to administer every 5 to 15 minutes as needed, while the November 2025 medication administration record indicated to use PRN as directed. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | The Program Director, Quality Assurance Associate, Program Specialists, and Program Managers have been retrained on the regulation. The medication was placed on the MAR on 11/25/25. |
11/25/2025
| Implemented |
| 6400.166(a)(10) | On 1/13/2025, Individual #1 was prescribed Cranberry 600mg with instructions to take 1 capsule by mouth once daily for urinary health. On 11/25/2025 at 12:43pm, it was observed that Individual #1's The November 2025 medication administration record did not include the administration times for this medication. This medication was omitted entirely from the November 2025 medication administration record.
On 11/25/2025 at 11:24am, it was observed that the following pro re nata medications prescribed to Individual #1 had scheduled administration times listed on the November 2025 medication administration record: Banophen 25mg with instructions to take 1 capsule by mouth 3 times a day as needed for itching; Ondansetron 4mg ODT with instructions to dissolve 1 tablet by mouth every 8 hours as needed for nausea or vomiting; and Pain Relief 500mg with instructions to take 2 capsules every 6 hours as needed while symptoms last. Do not take more than 6 caplets in 24 hours, unless directed by a doctor. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | The Program Director, Quality Assurance Associate, Program Specialists, and Program Managers have been retrained on the regulation. The medication was placed on the MAR on 11/25/25. |
11/25/2025
| Implemented |
| 6400.166(a)(11) | On 1/13/2025, Individual #1 was prescribed Cranberry 600mg with instructions to take 1 capsule by mouth once daily for urinary health. On 11/25/2025 at 12:43pm, it was observed that Individual #1's The November 2025 medication administration record did not include the diagnosis or purpose of this medication. This medication was omitted entirely from the November 2025 medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | The Program Director, Quality Assurance Associate, Program Specialists, and Program Managers have been retrained on the regulation. The medication was placed on the MAR on 11/25/25. |
11/25/2025
| Implemented |
| 6400.166(a)(12) | On 1/13/2025, Individual #1 was prescribed Cranberry 600mg with instructions to take 1 capsule by mouth once daily for urinary health. On 11/25/2025 at 12:43pm, it was observed that Individual #1's The November 2025 medication administration record did not include the dates and times this medication was administered to Individual #1. This medication was omitted entirely from the November 2025 medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration. | The Program Director, Quality Assurance Associate, Program Specialists, and Program Managers have been retrained on the regulation. The medication was placed on the MAR on 11/25/25. |
11/25/2025
| Implemented |
| 6400.166(a)(13) | On 1/13/2025, Individual #1 was prescribed Cranberry 600mg with instructions to take 1 capsule by mouth once daily for urinary health. On 11/25/2025 at 12:43pm, it was observed that Individual #1's The November 2025 medication administration record did not include the names and initials of the persons that administered the medication to individual #1. This medication was omitted entirely from the November 2025 medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | The Program Director, Quality Assurance Associate, Program Specialists, and Program Managers have been retrained on the regulation. The medication was placed on the MAR on 11/25/25. |
11/25/2025
| Implemented |
| 6400.166(a)(15) | On 11/25/2025 at 11:29am, it was observe that Epinephrine Injection 0.3mg prescribed to Individual #1 indicated on the pharmacy issued medication label to not exceed 3 doses per episode. The November 2025 medication administration record did not include this special precaution. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Special precautions, if applicable. | The Program Director, Quality Assurance Associate, Program Specialists, and Program Managers have been retrained on the regulation. The medication was placed on the MAR on 11/25/25. |
11/25/2025
| Implemented |
| 6400.166(b) | On 1/13/2025, Individual #1 was prescribed Cranberry 600mg with instructions to take 1 capsule by mouth once daily for urinary health. On 11/25/2025 at 12:43pm, it was observed that this medication was omitted entirely from Individual #1's November 2025 medication administration record. Upon further review, it was observed that this medication was never added to Individual #1's medication administration record when the medication was prescribed. From the time the medication was prescribed on 1/13/2025 through 11/25/2025, the staff administering this medication to individual #1 did not document the date and time of administration, nor did they document their name and initials at the time the medication was administered to Individual #1. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The Program Director, Quality Assurance Associate, Program Specialists, and Program Managers have been retrained on the regulation. The medication was placed on the MAR on 11/25/25. |
11/25/2025
| Implemented |