| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.76(a) | The screws were not secured to the steps leading to the pull-down attic. A bolt was dislodged from the left side, and the steps were determined to be unsafe to climb. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The pull-down attic steps were inspected and repaired to address the unsecured screws and dislodged bolt that made the steps unsafe to climb. All hardware was properly secured and the steps were restored to a safe condition on 3/4/26. |
03/04/2026
| Implemented |
| 6400.80(a) | A large amount of ice that was not salted or removed was observed on the sidewalk outside near the staff door. There were large icicles hanging above that had not been knocked down, which were dripping onto the sidewalk, causing re-freezing and increasing the potential fall risk. The icicles hanging over the walkway also posed a hazard with the potential of falling on a person walking underneath. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | The ice on the sidewalk near the staff entrance was salted to prevent potential falls. The icicles hanging above the walkway were addressed to eliminate the hazard of falling ice. A landscaping contractor inspected and cleaned the gutters on 3/2/26 to help prevent water from dripping onto the walkway and causing future slippery conditions. |
03/02/2026
| Implemented |
| 6400.111(a) | There was no fire extinguisher that licensing representatives were able to access or view in the attic of the home. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | A fire extinguisher was placed in the attic of the home to ensure one is available and accessible in that area as required. |
03/02/2026
| Implemented |
| 6400.144 | Individual #1's ISP indicates that fluid intake is to be tracked to avoid bowel impaction. It indicates that fluid intake is to be at minimum 64 ounces per day. The Associate Director stated that staff is to track fluid using the agency Evolve system on the computer or track it using a hard copy sheet in the individual's program book. However, staff were unable to produce any completed fluid tracking sheets at the time of inspection. There was also no evidence that communication is taking place between home and the day program regarding the total amount of fluid consumed throughout the day.
Individual #2 is prescribed PRN (as needed) Pain Relief Liquid 500/15ml. This medication was not in the home at the time of inspection. Staff had the medication in their car and stated it had been removed from the home because it had expired. When it was brought back into the home, the medication was full, unopened and not expired. Staff then stated that a new bottle would be coming from the individual's new pharmacy. It is unknown how long the medication had not been 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.
| Staff were reminded of the ISP requirement to monitor and document the individual's daily fluid intake to prevent bowel impaction and ensure the individual consumes at least 64 ounces of fluids per day. The Residential Lead indicated that fluid intake monitoring began following the inspection on 2/5/26. During follow-up, the provider reinforced expectations for documenting fluid intake and implemented a revised fluid tracking log in the home. Staff have been instructed to document fluid intake each shift using the tracking sheet located in the individual's program binder.
To ensure accurate daily totals, the provider will obtain the individual's fluid intake totals from the day program and add them to the home's daily tracking log so that fluid intake can be coordinated and documented across both settings.
Individual #2's PRN (as needed) Pain Relief Liquid 500/15ml was replaced in the home at the time of inspection. |
03/05/2026
| Implemented |
| 6400.166(a)(11) | The medication administration record (MAR) for individual #2 did not indicate a diagnosis or purpose for the medication, including pro re nata, for the following medications: Albuterol Neb 0.083%; Calcium Carb Sus 1250/5ml; Ergocalciferol-8000; Jabbonti INJ; Petrolatum OIN 42%; Erythromycin 0.5% Eye Ointment; Ocusoft Lid Scrub Pads; Refresh Opti drop 0.5-0.9%. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | It was identified that the MAR for Individual #2 did not reflect the diagnosis or purpose for several medications, including PRN medications. The agency nurse contacted the pharmacy on 3/5/26 to request updated prescription labels reflecting the appropriate diagnosis or purpose for the medications. Once received and confirmed, the information will be updated in the MAR to ensure compliance with medication documentation requirements. |
02/05/2026
| Implemented |
| 6400.166(b) | Individual #2 is prescribed Jubbonti INJ, which is injected every six months by the individual's doctor. It was initialed by staff as administered on the MAR on 2/1/26 and 2/2/26. However, staff do not administer this medication, and it was reportedly not administered until 2/4/26, where it was scheduled to be administered by the doctor at the individual's appointment in the office. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | It was identified that Jubbonti INJ, which is administered every six months by the individual's physician, was incorrectly initialed by staff on the MAR on 2/1/26 and 2/2/26. This medication is not administered by residential staff and was scheduled to be administered by the physician at the individual's medical appointment on 2/4/26. Staff will be re-educated on proper MAR documentation requirements, including that medications administered by a physician or other outside medical provider should not be documented as administered by residential staff. |
03/09/2026
| Implemented |