| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.110(e) | The smoke detectors in the home were not interconnecting smoke detectors. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | All wireless smoke detectors were reprogrammed and tested by maintenance contractor to ensure full interconnection throughout the home on 09/25/25. To be safe, the entire set of smoke detectors were replaced to avoid a situation where they disconnect. |
09/30/2025
| Implemented |
| 6400.144 | Medication Triamcinolon 0.1% Oint listed on the medical record for individual 1 was not observed in the home during the visit on 9/19/25. | 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 medication was ordered from the Pharmacy and placed in the home for i to be administered to the individual |
09/30/2025
| Implemented |
| 6400.165(c) | A review and count of medication (a 30 day supply of Culturelle Probiotic pills dispensed on 9/2/25) for individual 1 revealed that the individual was not administered their medication timely. The blister pack showed 13 pills missing on the 19th day of the month. | A prescription medication shall be administered as prescribed. | A retraining has been done with the House Supervisor and the staff in the home to comply with the guidance from the electronic MAR which does a complete count of medications administered. |
09/30/2025
| Implemented |
| 6400.166(a)(11) | The medical record log for Individual 1 did not state the diagnosis or purpose for any of the medications prescribed. | 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 pharmacy was notified and asked to update the MAR to show the diagnosis for all medications on the MAR |
09/24/2025
| Implemented |
| 6400.167(c) | Facility failed to report a medication error to the department timely. | A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). | The incident was entered into HCSIS by the Agency's Asset and Property Manager who is a Certified Investigator. |
09/30/2025
| Implemented |
| 6400.181(f) | There was no correspondence showing that the annual assessment was sent to the ISP team at least 30 days prior to the 06/17/25 ISP meeting for individual 1. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The Program Specialist has updated the annual monitoring compliance sheet to show a communication due date to all SCs between 60 and 30 days to the one year anniversary of the last annual ISP meeting. |
09/26/2025
| Implemented |
| 6400.182(a) | Individual 1's ISP does not state that poisons should be locked per the 05/16/25 assessment. | The program specialist shall coordinate the development of the individual plan, including revisions with the individual and the individual plan team. | Communication was sent to the SC by the Program Specialist to revise the ISP to state that poisons should be locked per the 05/16/25 assessment. The SC has revised the ISP to state as such and it was confirmed on the updated ISP |
09/30/2025
| Implemented |