| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.63(a) | On 5/29/25 at 11:11am the water temperature, taken from the bathroom sink on the right wing measured, 124.8F. The water temperature taken from the bathroom sink, on the left wing measured 123.8F at 11:15am | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | Residential Director adjusted the water temperature regulator on-site at the time of the violation. Thirteen out of fifteen homes have tankless hot water tanks with digital temperature controls that display the current temperature continuously. The 2 homes without will have anti-scald devices installed. |
05/29/2025
| Implemented |
| 6400.144 | On 5/29/25 at 11:43am, Individual #1's bed contained an under the mattress assist bar to aid the individual's mobility. When facing the individual's bed from the foot of the bed, the assist bar was located on the left side near the head of the bed. On 5/16/25, Individual #1's medical practitioner wrote a prescription indicating the individual was diagnosed with Alzheimer's and uses bedrails for safety, repositioning and to prevent her from falling out of bed. The agency failed to provide individual #1 with a "bedrail" as prescribed by the medical practitioner. | 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.
| On 5/29/2025 it was identified that the medical order for individual # 1 was inaccurate to the identified piece of DME in the home. The prescription order obtained by the individual's PCP states that the individual is diagnosed with Alzheimer's and that a hospital bed with side rails are necessary for safety, repositioning, and to prevent falling out of bed. This individual does not have a hospital bed with side rails as identified in the letter of medical necessity. PCP appointment to be made for the individual to identify and assess needs to ensure that proper equipment and prescription is secured to best fit her required needs. Medical appointment to be scheduled no later 7/18/2025. |
07/18/2025
| Implemented |
| 6400.181(e)(14) | On 5/28/29 Individual #2's assessment, dated 1/18/25, did not address Individual #2's knowledge of water safety and ability to swim. On 5/28/29 Individual #3's assessment, dated 1/18/25, did not address Individual #3's knowledge of water safety and ability to swim. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | On 5/28/25, the assessments for Individuals #2 and #3 did not address their knowledge of water safety or their ability to swim, as required. To correct this, the Program Specialist will assess both individuals on their water safety knowledge and swimming ability by 6/30/25. The assessments will be documented in each individual¿s record and then submitted to the Supports Coordinator to be incorporated into each Individual Support Plan (ISP), ensuring regulatory requirements are met and the plans accurately reflect the individuals¿ needs. |
06/30/2025
| Implemented |