| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.101 | The kitchen side of the door leading to the basement of the home had a padlock on the door posing an obstructed egress from the basement. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The padlock was removed from this location. |
08/07/2025
| Implemented |
| 6400.112(d) | The home had an extended evacuation time of 4 minutes and 30 seconds. The determination for the extended evacuation time did not include a statement attesting that the extended time and fire-safe area is based on the design and construction of the home and not on the needs of the individuals served. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | An updated Fire Evacuation letter was requested to the local Fire Department for evaluation and update. |
08/13/2025
| Implemented |
| 6400.141(c)(4) | Individual #1's physical examination dated 6/3/25 did not include vision and hearing screening as this was left blank on the exam form. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Physician was contacted to obtain an addendum/corrected physical form and/or provide a written summary outlining Hearing and Vision was checked at the time of the physical. |
08/14/2025
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination dated 6/3/25 did not include medical information pertinent to diagnosis and treatment in case of an emergency as this section was left blank on the form. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Physician was contacted to obtain an addendum/corrected physical form and/or provide a written summary outlining Hearing and Vision was checked at the time of the physical. |
08/14/2025
| Implemented |
| 6400.181(d) | Individual #1's assessment dated 7/21/25 did not include the program specialists' signature and date on the assessment as both these sections were left blank on the form/document. | The program specialist shall sign and date the assessment. | Program Specialist will upload the signed PDF version of the document into the EHR. |
08/15/2025
| Implemented |
| 6400.163(a) | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. At the time of the inspection, located in Individual #1's medication box was their prescribed Albuterol HFA Inhaler that was not in an original container, and this inhaler did not have a label issued by a pharmacy. Individual #1 is prescribed Nystatin 100000 unit/gm and at the time of the inspection the box of the Nystain medication was in with Individual #1's medication, however it did not contain a pharmacy label. Although, along the bottom of one side of the box appeared as though it could have once had a label of some sort on it at one time but, it was no longer on the box only the remains of a white substance on the box were left. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | Labels were obtained from the pharmacy for all medications pertaining to this individual. |
08/08/2025
| Implemented |
| 6400.165(a) | A prescription medication shall be prescribed in writing by an authorized prescriber. According to the Regulatory Compliance Guide (RCG) prescription medications include over the counter (OTC) medications for the purposes of compliance. At the time of the inspection, the following medications were located with Individual #1's medications: Equate Pain Relief Cream 4% Lidocaine HCL/Topical Analgesic, Equate Pain relieving Cream Lidocaine 4%, 2 bottles of Topcare Antacid Tablets, and 1 bottle of Multi-Symptoms Rolaids Advanced Antacid + Anti gas. None of these medications were prescribed/ordered to Individual #1 to ensure Individual #1 can take the medication and that they are not contraindicated. | A prescription medication shall be prescribed in writing by an authorized prescriber. | Request to the Physician was made to obtain proper documentation of the prescriptions, to include an updated medication list. |
08/13/2025
| Implemented |
| 6400.165(c) | Individual #1 is prescribed Nystatin 100000 unit/gm, apply externally twice daily. Prescribed on 7/16/2025 with a 30-day supply according to the prescription/order provided by the agency. At the time of the inspection, the tube of medication remained approximately full as it only had 2 small finger imprints on it. The Nystatin100000 unit/gm medication was also not recorded on Individual #1's July or August 2025 Medication Administration Record (MAR). The medication is not being administered as prescribed. | A prescription medication shall be administered as prescribed. | An investigation was commenced.
((The following steps were taken as per EIM 9676108: Retrain appropriate staff on existing policy and/or procedure
and evaluate effectiveness -10/1/25 CH)) |
08/15/2025
| Implemented |
| 6400.166(a)(4) | At the time of the inspection, Individual #1's Nystatin and Albuterol HFA inhaler were not on the August 2025 Medication Administration Record (MAR). As per the Regulatory Compliance Guide (RCG) prescription medication and Pro re nata (PRN) medications must be recorded on the medication record. The MAR did not include the name of the medication, strength of the medication, dosage form, dose of the medication, route of administration, frequency of administration, or diagnosis or purpose for the medications. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | The individuals Medication History and MAR have been updated upon receiving the labels. |
08/15/2025
| Implemented |
| 6400.195(a) | At the time of the inspection, on the wall in the kitchen next to the table on a purple cut out flower that had black lettering written on it that stated, "Cigarettes 7am-get 3 7pm-get 3". Agency staff stated to the Licensing Representative (LR) that the wall is a reminder wall for Individual #1, and that the rest of her cigarettes are kept in the office area. Agency staff also provided the LR with a nursing care communication order dated 7/3/25 and approximately ¾ of the way down it noted comments 3 cigarettes per 12 hour period. The provider is limiting the number of cigarettes the individual can smoke and have access to during the day. There is no Restrictive Procedure Plan in place for Individual #1. | For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures. | The restrictions have been ceased for the individual while the Restrictive Procedure Plan is being developed for review by the HRT. |
08/06/2025
| Implemented |