| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.144 | Per the physical completed on 5/29/25 Individual #1 is prescribed a diet that is chopped, gluten free, lactose free and a Fodmap diet.
At time of inspection 4C Plain Breadcrumbs were found in the kitchen cabinet to the left of the stove.
Financial records illustrated that Individual #1 has made weekly, sometimes more, trips to Dunkin Donuts and Sheetz to purchase munchkins, donuts, Herr's PB filled pretzels, Kit Kat bars, and Herr's chocolate covered pretzels. The items listed are not gluten free.
Additional items in question are what was noted as "smoothies" at Dairy Queens, sesame chicken and chicken parm.
Documentation supports that the prescribed diet has not been followed at all times.
Individual #1 was seen by their dermatologist on 9/4/24 with direction to return in "6-8 months." There was no documentation that the appointment occurred as directed and no documentation to explain the missed appointment. A notation on 7/31/25 notes that "never got scheduled with HS specialist." The appointment was now scheduled for 5/29/26. Updated information received indicates that the appointment should now take place in November of 2025. | 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.
| Nursing staff trained all staff in the home on Individual #1's prescribed diet and the importance of adhering to the diet for Samantha's well-being. Nursing staff also trained all staff in the home on following physician's orders and following scheduling guidelines for all follow up appointments. Nursing staff stressed the need for all contact with doctor's offices in scheduling appointments should be well before the follow up window and contact with doctor's should always be documented on agency doctor phone consult forms. The Program Specialist of Individual #1 trained staff in the home on grocery shopping for Individual #1's prescribed diet as well as following Individual #1's diet while out in the community and assisting her in picking out and purchasing items that comply with her prescribed diet. |
12/31/2025
| Implemented |
| 6400.32(i) | At time of inspection, it was noted that access to some of Individual 1's possessions was blocked by the locked cellar landing door. This locked area contained an unopened box of bath bombs that were not considered poisons, their hairdryer, combs and hairbrushes, toothbrush, a sand art kit, a tote containing crayons and markers, a bubble machine, and scratch fantastic book. Individuals have the right to access their possessions. | An individual has the right of access to and security of the individual's possessions. | Upon notification and realization that overflow of personal items were kept behind a locked door, all personal items were moved to Individual #1's personal bedroom and living area where she had unrestricted access. Individual #1's Program Specialist re-trained all staff in the home on the importance of Individuals having access to personal items and that only poisonous items should be locked. |
12/31/2025
| Implemented |
| 6400.163(h) | Individual #1 is prescribed Chlorhexidine Gluconate to "swab on teeth and gums three times a week." At time of inspection the bottle in use was pharmacy labeled as filled on 10/3/24 with an expiration date on the pharmacy label as 10/3/25. Expired medications taken out of use and shall be destroyed in a safe manner. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Although there was an unexpired bottle of medication in the home, the expired one remained and was not disposed of properly. All staff in the home were trained by nursing staff on following expiration dates on bottles and proper disposal of expired medications. |
11/10/2025
| Implemented |
| 6400.165(c) | Individual #1 is prescribed Chlorhexidine Gluconate to "swab on teeth and gums three times a week." At time of inspection the bottle in use was pharmacy labeled as filled on 10/3/24 and was nearly half full. Administered as prescribed and at the recommended 15ml per dose the bottle in use should have been replaced by approximately 1/31/25.
Individual #1 is prescribed Sodium Floride 5000 plus toothpaste which was filled on 3/19/25 and is to be administered as "use a pea sized amount twice daily as toothpaste." The 51g tube contains approximately 204 .25g pea sized administrations. At twice daily as prescribed, 102 administrations are in the tube. If administered as prescribed the tube in use filled on 3/19/25 should have been empty by approximately 7/1/25. A second full tube was found in the home and dated as filled on 9/22/25. | A prescription medication shall be administered as prescribed. | All staff who work with individual #1 were re-trained on proper medication administration of the mouth wash and the importance of administrating medications as prescribed. Emphasis was placed on staff using proper dosing when swabbing the mouth wash on Individual #1's teeth and gums and when administering toothpaste on Individual #1's toothbrush prior to brushing her teeth. |
11/10/2025
| Implemented |