| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(d) | The fire drill conducted on October 21, 2025, at 11:20 PM had a duration of 2 minutes and 42 seconds. No further fire drills were attempted in October 2025. | 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. | Staff will be retrained by the Associate Director on conducting fire drill in the required time of 2 1/2 minutes. If the evacuation times exceeds 2 1/2 minutes, the drill will be repeated until the required evacuation time is achieved. The staff review and be trained on the fire evacuation procedures and identify any barriers that may contribute to the extended evacuation time. Each fire drill will be accurately documented, including date, time, evacuation duration, individual/staff participating, and any issues identified. |
09/30/2026
| Implemented |
| 6400.144 | The Medication Administration Record (MAR) for individual 2 indicated the medication Glucose 15 Gel, with instructions to use one tube for blood sugar levels exceeding 70. At the time of inspection, this medication was not available in the home. | 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 individual medication orders and Medication Administration Record will be reviewed to verify that all current prescribed medications are available in the home. The missing medication was obtained promptly and made available for administration as prescribed. The Wellness department will be notified as appropriate; to determine whether any additional actions is needed regarding the individuals sugar management and prescribed medication. The medication supply will be reviewed routinely to identify medications that are running low, unavailable, expired or require replacement or discontinuation. |
07/10/2026
| Implemented |
| 6400.144 | During the physical examination of Individual 2 on April 3, 2026, under the Hearing Screening section, it was recommended that a specialist be consulted for further evaluation. However, there is no documentation indicating that this consultation took place or that any progress has been made. | 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 individual's physician will be contacted to coordinate the recommended specialist consultation. A referral appointment with a hearing specialist will be schedule. The Associate Director will be remined that all recommendations for follow-up appointment or specialist consultation must be tracked through completion. If an appointment cannot be obtained promptly, the reason for the delay and ongoing efforts to secure that appointment will be documented. |
07/10/2026
| Implemented |