| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.76(a) | On 7/23/2025 at 12:37pm, the blind covering the window at the foot of Individual #3's bed was in disrepair with 5 broken horizontal slats near the bottom of the blind. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The blind covering the window at the foot of Individual #3's bed will be replaced. |
08/01/2025
| Implemented |
| 6400.141(c)(9) | Individual #1's physical examination, completed 7/3/2025, did not include a prostate examination. | The physical examination shall include: A prostate examination for men 40 years of age or older. | Individual #1 is scheduled for a prostate exam on 09/08/2025 with urology |
09/08/2025
| Implemented |
| 6400.181(a) | Individual #1, date of admission 5/21/2025, had their initial residential assessment completed on 7/21/2025; 61 days after their admission into the program. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Individual's assessment was completed 7/21/25. |
07/21/2025
| Implemented |
| 6400.214(b) | On 7/23/2025 at approximately 12:30pm, the following documents from Individual #1's record were not accessible at the residential home: current physical examination and current dental examination. The agency utilizes Therap to digitally store individual record information; however, these documents had not been uploaded to Individual #1's electronic record. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| The most current copies of record information required in § 6400.213(2)(14) will be uploaded to an electronic file accessible to staff in all ResHab locations. |
09/15/2025
| Implemented |
| 6400.207(5)(II) | On 7/23/2025 at 12:38pm, Individual #2's bed contained bilateral upper-half bedrails that restricted the movement or function of the individual's body. The agency obtained a prescription for bed rails on 5/13/2025. Although the bed rails are prescribed by the medical practitioner, Individual #2's most current assessment, completed 9/10/2024, does not address if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual. Individual #2's support plan last updated 7/9/2025 does indicate the need for a hospital style bed with rails; however, it does not include periodic relief of the device to allow freedom of movement. | A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Balance or support to achieve functional body position, if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement. | Bedrails will be removed from individual #2's bed. Wedges will be used to ensure the individual¿s safety. Staff will continue to reposition the individual every 2 hours and document overnight. |
08/15/2025
| Implemented |