| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.64(a) | Clean and sanitary conditions shall be maintained in the home. There was a very pungent odor of what appeared to be urine all throughout the house and back porch. The bathroom on the main level of the home next to the kitchen had a black like substance resembling mold/mildew all along seems off the plastic walls in the inside of the shower. | Clean conditions shall be maintained in all areas of the home. | Provider will ensure that the bathroom is free of any and all substances within the bathroom, to include inside of the shower and then will be completing recalking as necessary. |
09/12/2025
| Implemented |
| 6500.79(d) | Bedroom windows shall have drapes, curtains, shades, blinds or shutters. Individual #1's bedroom located closest to his door did not have drapes, curtains, shades, blinds or shutters. The bottom half of the window had window frosting on it, however the top part of the window did not and did not provide privacy. | Bedroom windows shall have drapes, curtains, shades, blinds or shutters. | Provider will purchase curtains for the window in the individuals bedroom. |
09/12/2025
| Implemented |
| 6500.107(a) | The home shall have a minimum of one operable automatic smoke detector provided on each floor, including the basement and attic. The smoke detector for the basement was located at the top of the basement steps on the level where the laundry room area was not in the basement area. | A home shall have a minimum of one operable automatic smoke detector provided on each floor, including the basement and attic. | Smoke detector for the basement was moved to the bottom of the stairwell and the smoke detector for the attic was moved to the top of the stairwell. |
09/12/2025
| Implemented |
| 6500.121(c)(14) | The annual physical examination completed on 7/25/2025 for Individual #1 did not include documentation of medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Provider requested physician to provide updated and corrected physical form that includes medical information pertinent to diagnosis and treatment in case of an emergency. |
09/03/2025
| Implemented |
| 6500.47(b)(5) | During the inspection, the Licensing Representative (LR) asked Staff #2 about Individual #1's Pro Re Nata (PRN) medications and Staff #2 appeared to have no knowledge of what PRN medications were prescribed for Individual #1, where to locate these medications, or where to obtain information on what PRN medications were prescribed. Staff #2 brought multiple over-the-counter (OTC) PRN medications to the LR and would inquire if they were the correct medication. They also provided medications that were not prescribed/ordered for Individual #1. Staff must be trained on job related knowledge and skills which would include the medications prescribed to the individual and where to find pertinent information related to the care of the individual. | The orientation must encompass the following areas: Job-related knowledge and skills. | Provider will receive retraining on job related knowledge and skills. |
09/19/2025
| Implemented |
| 6500.48(b)(4) | Staff #1 did not complete training in Incident Management as part of the annual training hours during training year Calendar 2024. | The annual training hours specified in subsection (a) must encompass the following areas: Recognizing and reporting incidents. | Provider completed incident management training on 1/17/2025 and previously on 1/26/2024. |
01/26/2024
| Implemented |
| 6500.131(b) | Individual #1 is assessed as capable of self-administering medications. Individual #1's medications are stored in a clear 31-day pill organizer. Staff #2 reports that they fill the pill organizer with the medications for Individual #1. When assisting with self-administration of medications, staff may not remove the medication from its original container. | Assistance in the self-administration of medication includes helping the individual to remember the schedule for taking the medication, offering the individual the medication at the prescribed times, opening a medication container and storing the medication in a secure place. | The individual was determined to no longer be able to self-medicate and the use of the dispenser was discontinued. The provider will be administering medications moving forward. |
10/13/2025
| Implemented |
| 6500.131(e)(2) | : Individual #1 is assessed as capable of self-administering medications. Individual #1 is prescribed Vitamin D2 1.25, take 1 capsule by mouth once a week. The pharmacy label on the medication had "12 cap" as the amount dispensed on 6/25/25. As of 8/12/25, there were 7 pills remaining in the medication bottle and 2 pills remaining in Individual #1's 31-day pill organizer for a total of 9 pills remaining. If medications were being administered as instructed, there should only be 3 pills remaining. Individual #1 is not taking the correct amount of medication as prescribed.
(the count of 3 is starting the week after the 6/25/25) | To be considered able to self-administer medications, an individual shall do all of the following: Know how much medication is to be taken. | Team meeting conducted to determine if the individual should continue to self medicate. |
09/26/2025
| Implemented |
| 6500.135(a) | At the time of the inspection, Staff #2 provided Tums Antacids and cough drops to the Licensing Representative as medication for Individual #1 that are Pro Re Nata (PRN) medications. However, neither of these medications were listed on Individual #1's over-the-counter (OTC) list as being prescribed/ordered to Individual #1. The agency would want to ensure Individual #1 can take the medications and that they're not contradictive of their other medications. | A prescription medication shall be prescribed in writing by an authorized prescriber. | Provider will ensure that all medications to include OTC's are prescribed by a physician prior to administration. |
09/08/2025
| Implemented |
| 6500.135(c) | Individual #1 is prescribed Tylenol 650 mg. At the time of the inspection, what was available and in the home for Individual # 1 was Tylenol Extra Strength 500 mg and Pain relief acetaminophen 325mg. | A prescription medication shall be administered as prescribed. | Provider has purchased the correct medication of Tylenol 650mg and disposed of the other two forms of acetaminophen. |
09/08/2025
| Implemented |
| 6500.135(g) | If a medication is prescribed to treat the symptoms of a psychiatric illness, there shall be a review with documentation by a licensed physician at least every three months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. Individual #1 is prescribed medication to treat the symptoms of a psychiatric illness and reviews with a licensed physician did occur at least every three months as required, but several of the reviews did not include documentation of the reason for prescribing the medications, the need to continue the medication and the necessary dosage. The reviews that did not include the required documentation are as follows:
· 8/01/2025 -- necessary dosage and reason prescribed was not documented
· 7/14/2025 -- necessary dosage was not documented
· 6/24/2025 -- necessary dosage and reason prescribed was not documented
· 6/02/2025 -- necessary dosage was not documented
· 4/23/2025 -- necessary dosage was not documented
· 11/20/2024 -- reason prescribed was not documented | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review by a licensed physician at least every 3 months to document the r reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Provider requested corrected forms from the Primary Care Physician who oversees the psychotropic medication management of the individual. |
09/03/2025
| Implemented |