| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(a) | Individual #2, date of admission 10/6/2025, did not have a physical examination completed within 12 months prior to their admission. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual is already admitted and has had their physical, hearing, eye exam, TB test, and vaccinations with 1 week of being admitted. Individual #2 then had their next annual physical 4/27/2026. Cannot correct that Individual #2's family did not take them prior to admission, but all further physicals/hearing/eye exam/TB test/ and vaccinations will be kept current. |
05/31/2026
| Implemented |
| 6400.141(c)(3) | Individual #2's tetanus and diphtheria vaccination was administered after their admission at their physical examination on 10/13/2025. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Individual is already admitted and has had their physical, hearing, eye exam, TB test, and vaccinations with 1 week of being admitted. Individual #2 then had their next annual physical 4/27/2026. Cannot correct that Individual #2's family did not take them prior to admission, but all further physicals/hearing/eye exam/TB test/ and vaccinations will be kept current. |
05/31/2026
| Implemented |
| 6400.141(c)(4) | Individual #1, date of admission 6/9/2025, did not have a hearing screening completed within 1 year prior to their admission. Individual #1's physical examinations were completed on 5/30/2025 and again on 4/2/2026; however, the individual's primary care physician did not complete a hearing screening during these examinations.
Individual #2, date of admission 10/6/2025, did not have a vision or hearing screening completed within 1 year prior to their admission. Individual #2's vision and hearing screenings were completed after their admission at their physical examination on 10/13/2025. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Individual is already admitted and has had their physical, hearing, eye exam, TB test, and vaccinations with 1 week of being admitted. Individual #2 had their next annual physical 4/27/2026. Cannot correct that Individual #1's family did not take them prior to admission, but all further physicals/hearing/eye exam/TB test/ and vaccinations will be kept current. |
05/31/2026
| Implemented |
| 6400.141(c)(6) | Individual #2, date of admission 10/6/25, had a tuberculin skin test completed after their admission at their physical examination on 10/13/2025. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Individual is already admitted and has had their physical, hearing, eye exam, TB test, and vaccinations with 1 week of being admitted. Individual #2 had their next annual physical 4/27/2026. Cannot correct that Individual #2's family did not take them prior to admission, but all further physicals/hearing/eye exam/TB test/ and vaccinations will be kept current. |
05/31/2026
| Implemented |
| 6400.141(c)(7) | Individual #1, date of admission 6/9/2025, did not have a gynecological examination including a breast examination and a Pap test completed within 1 year prior to their admission. Only after Individual #1's admission, the agency obtained a letter from Individual #1's primary care physician, dated 6/30/2025, stating due to Individual #1's dementia diagnosis, it would be too traumatic to complete a gynecological examination or breast examination and because Individual #1 is not sexually active, a Pap Test is unnecessary. | 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. | Individual is already admitted, so cannot correct that the letter was obtained after her admission. Also, this individual passed away on 4/24/2026. |
05/31/2026
| Implemented |
| 6400.141(c)(8) | Individual #1, date of admission 6/9/2025, did not have a mammogram completed within 1 year prior to their admission. Only after Individual #1's admission, the agency obtained a letter from Individual #1's primary care physician, dated 6/30/2025, stating due to Individual #1's dementia diagnosis, it would be too traumatic to complete a mammogram. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | Individual is already admitted, so cannot correct that the letter was obtained after admission. Also, this individual passed away on 4/24/2026. |
05/31/2026
| Implemented |
| 6400.151(a) | Direct Service Worker #1 completed their physical examinations on 3/8/2024 and again on 3/13/2026. This exceeds the every 2-year requirement. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | This staff will be scheduled for their next bi annual physical before 3/13/2028. |
05/31/2026
| Implemented |
| 6400.214(b) | On 4/15/2026 at approximately 10:40am, the following content from Individual #1's record was not available on-site in the residential home: assessment last updated 12/9/2025, physical examination completed 4/2/2026, dental examination including dental hygiene plan completed 10/15/2025, and current incident reports. On 4/15/2026 at approximately 10:45am, the following content from Individual #2's record was not available on-site in the residential home: assessment last updated 2/10/2026, physical examination completed 10/13/2025, dental examination including dental hygiene plan completed 11/19/2025, and current incident reports. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| Residential manager created a copy of the individual's assessments, physical examinations, dental examination and dental hygiene plan and took hard copies to the residential homes. She also reviewed all other individual's records at the home and provided updated copies for them as well. |
04/17/2026
| Implemented |
| 6400.165(a) | On 4/15/2026 at 10:18am, a bottle of Clindamycin 300mg capsules with instructions to "take 2 capsules by mouth 1 hour prior to procedure" was observed amongst Individual #1's prescription medications. The medication had previously been prescribed to Individual #1 and the pharmacy issued label had a dispense date of 9/19/2025. Per discussions with agency staff, it was reported that the agency never obtained a written order for this medication. Individual #1's legal guardian obtained the prescription medication prior to a dental procedure and provided the medication to the agency. The written order was not provided along with the prescribed medication. | A prescription medication shall be prescribed in writing by an authorized prescriber. | This medication was taken and destroyed by the residential program nurse. |
04/15/2026
| Implemented |
| 6400.166(b) | On 4/15/2026 at 10:30am, it was observed that the following medications prescribed to Individual #2 had not been documented as administered by Direct Service Worker #1 at 8:00am on 4/15/2026 on the April 2026 medication administration record: Aspirin 81mg tablet with instructions to "chew 1 tablet by mouth every morning for heart health"; Clobazam 10mg tablet with instructions to "give one 10mg tablet twice daily AM/PM for epilepsy"; D3 CAP 1000 UNIT with instructions to "take 1 capsule by mouth every morning for supplement"; Docusate Sodium 100mg capsule with instructions to "take 1 capsule by mouth twice a day for constipation"; Gabapentin 600mg tablet with instructions to "take 1 tablet by mouth three times daily"; Levetiracetam 1000mg tablet with instructions to "take 1 tablet by mouth twice a day for seizures"; Tamsulosin 0.4mg tablet with instructions to "take 1 tablet by mouth twice a day for prostate"; and Topiramate 200mg tablet with instructions to "give 1 (200mg) tablet twice daily for epilepsy." | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | DSP signed medication administration record as administered and attended a retraining on proper administration and documentation of medications on 4/20/2026 |
04/20/2026
| Implemented |
| 6400.207(5)(III) | On 4/15/2026 at 11:03am, Individual #1's bed contained bilateral full bedrails that restricted the movement or function of the individual's body. The agency obtained a prescription for bed rails during Individual #1's physical examination on 4/2/2026; however, the order did not include the diagnosis for which the device was intended to treat. Although the bed rails are prescribed by the medical practitioner, Individual #1's assessment, last updated 12/9/2025, did not indicate 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 #1's support plan, last updated 4/7/2026, did not include periodic relief of the device to allow freedom of movement. On 4/15/2026 at 11:01am, 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 half bed rails on 4/8/2025; however, the order did not include the diagnosis for which the device was intended to treat. Although the bed rails are prescribed by the medical practitioner, Individual #2's assessment, last updated 2/10/2026, did not indicate 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 3/23/2026, did 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: Protection from injury during a seizure or other medical condition, 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. | Program manager updated annual assessment to include 1) type of bedrail, 2) why it is needed and 3) how the individual is able to get relief from the bed rail. Residential program nurse obtained updated physician's orders to include the diagnosis of why the bedrails are needed. Program manager emailed the updated assessment and updated order from the physician to the SC requesting ISP to be updated accordingly. Email is kept on file. |
05/31/2026
| Implemented |