| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.17(b) | The agency used a Department's licensing inspection instrument modified in June 2018 to complete the self-assessment of the home on 4/30/26. The current licensing inspection summary instrument for the community homes for individuals with intellectual disability or autism regulations was promulgated in February 2020. | The agency shall use the Department's licensing inspection instrument for this chapter to measure and record compliance. | May 29, 2026- The assessment was completed by the residential director using the current licensing inspection summary instrument required for community homes serving individuals with intellectual disabilities or autism, ensuring compliance with all elements of the Office of Developmental Programs within 6500 regulations. |
05/29/2026
| Implemented |
| 6500.24(e)(1) | The financial section of Individual #1's individual plan that was last updated on 2/20/26, reads, "[Individual #1] lacks money management skills and has no desire to learn money management skills. [Individual #1]'s representative payee, [Family Living Provider #1] manages his finances and meets any financial obligations as they arise." At 3:24PM, interviews also revealed that Family Living Provider #1 is the representative payee for Individual #1 and assists Individual #1 with his financial resources. Interviews revealed that Family Living Provider #1 does not keep any type of financial record for deposits or withdrawals of Individual #1's financial resources. | If the agency or family assumes the responsibility for an individual's financial resources, the following shall be maintained: a separate record of financial resources including the dates and amounts of deposits and withdrawals. | May 27, 2026 -- The Program Specialist completed an audit of Individual #1's financial records and identified that a separate record documenting all deposits and withdrawals was not being consistently maintained. A financial ledger was immediately created and updated to accurately reflect all available transactions, including the dates and amounts of deposits and withdrawals.
May 27, 2026 -- The Program Director provided retraining to the Program Specialist and staff #1 on financial management requirements, emphasizing the need to maintain a separate, accurate, and current record of all individual financial transactions. |
05/27/2026
| Implemented |
| 6500.151(e)(2) | Individual #1's assessment that was completed on 3/5/26 does not include dislikes of the individual. | The assessment must include the following information: The likes, dislikes and interest of the individual. | May 29, 2026 - the Program Director updated the Individual Assessment to include a section that assesses individual's dislikes.
June 1, 2026- The Program Specialist reassessed Individual #1 and completed the newly added section regarding the individual's dislikes to ensure the assessment accurately reflects their preferences and support needs |
06/01/2026
| Implemented |
| 6500.151(e)(12) | Individual #1's assessment that was completed on 3/5/26 does not contain recommendations for specific areas of training, programming or services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | May 29, 2026 - the Program Director updated the Individual Assessment to include a section that assesses recommendations for specific area of training, programming, and services.
June 1, 2026 -- The Program Specialist reassessed Individual #1 and completed the newly added section regarding recommendations for specific areas of training, programming, and services to ensure the assessment accurately reflects the individual's needs, preferences, and support requirements. |
06/01/2026
| Implemented |
| 6500.151(e)(13)(i) | Individual #1's assessment that was completed on 3/5/26 does not contain the individual's progress over the last 365 days in following area: Health. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: Health. | May 29, 2026 -- The Program Director updated the Individual Assessment to include a section that evaluates the individual's progress over the previous 365 calendar days and documents their current health status. This addition helps ensure a comprehensive review of the individual's growth, support needs, and overall well-being.
June 1, 2026 -- The Program Specialist reassessed Individual #1 and completed the newly added section regarding the individual's current health status and health-related developments over the previous 365 calendar days. |
06/01/2026
| Implemented |
| 6500.151(e)(13)(ii) | Individual #1's assessment that was completed on 3/5/26 does not contain the individual's progress over the last 365 days in following area: Motor and communication skills. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | May 29, 2026 - the Program Director updated the Individual Assessment to include a section that assesses the individual's progress over the last 365 calendar days and current level in their motor and communication skills.
June 1, 2026 -- The Program Specialist reassessed Individual #1 and completed the newly added section regarding the individual's current motor and communication skills over the previous 365 calendar days. |
06/01/2026
| Implemented |
| 6500.151(e)(13)(iii) | Individual #1's assessment that was completed on 3/5/26 does not contain the individual's progress over the last 365 days in following area: Activities of residential living. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | May 29, 2026 -- The Program Director updated the Individual Assessment to include a section that assesses the individual's progress over the previous 365 calendar days and their current level of participation in residential activities.
June 1, 2026 -- The Program Specialist reassessed Individual #1 and completed the newly added section regarding the individual's current level of participation in residential activities and progress made over the previous 365 calendar days. |
06/01/2026
| Implemented |
| 6500.151(e)(13)(iv) | Individual #1's assessment that was completed on 3/5/26 does not contain the individual's progress over the last 365 days in following area: Personal adjustment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | May 29, 2026 -- The Program Director updated the Individual Assessment to include a section that assesses the individual's progress over the previous 365 calendar days and their current level of personal adjustment.
June 1, 2026 -- The Program Specialist reassessed Individual #1 and completed the newly added section regarding the individual's current level of personal adjustment and progress made over the previous 365 calendar days to ensure the assessment accurately reflects the individual's current functioning and support needs. |
06/01/2026
| Implemented |
| 6500.151(e)(13)(v) | Individual #1's assessment that was completed on 3/5/26 does not contain the individual's progress over the last 365 days in following area: Socialization. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | May 29, 2026 -- The Program Director updated the Individual Assessment to include a section that assesses the individual's progress over the previous 365 calendar days and their current level of socialization.
June 1, 2026 -- The Program Specialist reassessed Individual #1 and completed the newly added section regarding the individual's current level of socialization and progress made over the previous 365 calendar days to ensure the assessment accurately reflects the individual's current functioning and support needs. |
06/01/2026
| Implemented |
| 6500.151(e)(13)(vi) | Individual #1's assessment that was completed on 3/5/26 does not contain the individual's progress over the last 365 days in following area: Recreation. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | May 29, 2026 -- The Program Director updated the Individual Assessment to include a section that assesses the individual's progress over the previous 365 calendar days and their current level of participation in recreational activities.
June 1, 2026 -- The Program Specialist reassessed Individual #1 and completed the newly added section regarding the individual's current level of participation in recreational activities and progress made over the previous 365 calendar days to ensure the assessment accurately reflects the individual's interests, engagement, functioning, and support needs. |
06/01/2026
| Implemented |
| 6500.151(e)(13)(vii) | Individual #1's assessment that was completed on 3/5/26 does not contain the individual's progress over the last 365 days in following area: Financial independence. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence. | May 29, 2026 -- The Program Director updated the Individual Assessment to include a section that assesses the individual's progress over the previous 365 calendar days and their current level of financial independence.
June 1, 2026 -- The Program Specialist reassessed Individual #1 and completed the newly added section regarding the individual's current level of financial independence and progress made over the previous 365 calendar days to ensure the assessment accurately reflects the individual's financial skills, functioning, and support needs. |
06/01/2026
| Implemented |
| 6500.151(e)(13)(viii) | Individual #1's assessment that was completed on 3/5/26 does not contain the individual's progress over the last 365 days in following area: Managing personal property. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas : Managing personal property. | May 29, 2026 -- The Program Director updated the Individual Assessment to include a section that assesses the individual's progress over the previous 365 calendar days and their current level of managing personal property.
June 1, 2026 -- The Program Specialist reassessed Individual #1 and completed the newly added section regarding the individual's current level of managing personal property and progress made over the previous 365 calendar days to ensure the assessment accurately reflects the individual's ability to maintain, organize, and safeguard personal belongings, as well as their support needs in this area. |
06/01/2026
| Implemented |
| 6500.151(e)(13)(ix) | Individual #1's assessment that was completed on 3/5/26 does not contain the individual's progress over the last 365 days in following area: Community integration. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community integration. | May 29, 2026 -- The Program Director updated the Individual Assessment to include a section that assesses the individual's progress over the previous 365 calendar days and their current level of community integration.
June 1, 2026 -- The Program Specialist reassessed Individual #1 and completed the newly added section regarding the individual's current level of community integration and progress made over the previous 365 calendar days to ensure the assessment accurately reflects the individual's participation in community activities, relationships, access to community resources, and support needs. |
06/01/2026
| Implemented |
| 6500.136(a)(4) | At 3:20PM, Individual #1 had a prescription bottle of Lisinopril 20mg tab that was filled on 4/26/26. The name of this medication is not listed on the May 2026 medication record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | May 21, 2026 -- The Program Specialist reviewed Individual #1's May 2026 Medication Administration Record (MAR) and identified that Lisinopril 20 mg was not listed on the medication record. The MAR was immediately corrected to include the medication name as prescribed and reflected on the pharmacy-labeled container.
May 21, 2026 -- The Agency Nurse verified the accuracy of the MAR against the current physician orders and pharmacy label to ensure all prescribed medications were properly documented.
May 29, 2026 -- Staff #1 responsible for maintaining medication records received retraining regarding medication documentation requirements, including the requirement that the name of each prescribed medication be accurately recorded on the MAR. |
05/29/2026
| Implemented |
| 6500.136(a)(5) | At 3:18PM, Individual #1 has a current prescription bottle of Propranolol Hydrochloride Er 24hr 120mg capsule, however the May 2026 medication record listed this medication as Propranolol 80mg Er capsule. At 3:20PM, Individual #1 has a prescription bottle of Lisinopril 20mg tab that was filled on 4/26/26. The strength of this medication is not listed on the May 2026 medication record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | May 21, 2026 -- The Program Specialist reviewed Individual #1's May 2026 Medication Administration Record (MAR) and identified discrepancies between the physician's orders, medication labels, and the MAR. Specifically, Propranolol Hydrochloride ER 120 mg was incorrectly listed as Propranolol ER 80 mg, and the strength of Lisinopril was omitted from the MAR.
May 21, 2026 -- The MAR was immediately corrected to accurately reflect the medication name and strength as prescribed. The Agency Nurse verified the corrections against the current physician orders and pharmacy-labeled containers to ensure accuracy.
May 29, 2026 -- Staff #1 responsible for medication administration and MAR transcription received retraining on medication documentation requirements, including ensuring that all prescribed medications are recorded accurately and that the strength of each medication is documented on the MAR ensuring that all prescribed medications are recorded accurately and that the strength of each medication is documented on the MAR. |
05/29/2026
| Implemented |
| 6500.136(a)(6) | At 3:20PM, Individual #1 had a prescription bottle of Lisinopril 20mg tab that was filled on 4/26/26. The dosage form of this medication is not listed on the May 2026 medication record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | May 21, 2026 -- The Program Specialist reviewed Individual #1's May 2026 Medication Administration Record (MAR) and identified that the dosage form for Lisinopril 20 mg tablet was not documented. The MAR was immediately corrected to include the appropriate dosage form as indicated on the pharmacy-labeled container and physician order.
May 21, 2026 -- The Agency Nurse verified the accuracy of the medication record to ensure all required medication information, including dosage form, was accurately documented.
May 29, 2026 -- Staff #1 responsible for medication record maintenance received retraining on medication documentation requirements, including the requirement that the dosage form of each prescribed medication be accurately recorded on the MAR. |
05/29/2026
| Implemented |
| 6500.136(a)(7) | At 3:20PM, Individual #1 had a prescription bottle of Lisinopril 20mg tab that was filled on 4/26/26. The dose of this medication is not listed on the May 2026 medication record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | May 21, 2026 -- The Program Specialist reviewed Individual #1's May 2026 Medication Administration Record (MAR) and identified that the dose of Lisinopril was not documented. The MAR was immediately corrected to reflect the prescribed dose of 20 mg as indicated on the pharmacy-labeled container and current physician order.
May 21, 2026 -- The Agency Nurse reviewed the medication record and verified that all medication information accurately matched the physician order and pharmacy label.
May 29, 2026 -- Staff #1 responsible for maintaining medication records received retraining regarding medication documentation requirements, including the requirement that the dose of each prescribed medication be accurately documented on the MAR. |
05/29/2026
| Implemented |
| 6500.136(a)(8) | At 3:20PM, Individual #1 had a prescription bottle of Lisinopril 20mg tab that was filled on 4/26/26. The route of administration for this medication is not listed on the May 2026 medication record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | May 21, 2026 -- The Program Specialist reviewed Individual #1's May 2026 Medication Administration Record (MAR) and identified that the route of administration for Lisinopril 20 mg tablet was not documented. The MAR was immediately corrected to reflect the prescribed route of administration as indicated on the physician order and pharmacy-labeled container.
May 21, 2026 -- The Agency Nurse verified the accuracy of the medication record and confirmed that all required medication information was consistent with the current physician order and pharmacy label.
May 29, 2026 -- Staff #1 responsible for medication documentation received retraining regarding medication record requirements, including the requirement that the route of administration for each prescribed medication be accurately documented on the MAR. |
05/29/2026
| Implemented |
| 6500.136(a)(9) | At 3:20PM, Individual #1 had a prescription bottle of Lisinopril 20mg tab that was filled on 4/26/26. The frequency of administration for this medication is not listed on the May 2026 medication record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | May 21, 2026 -- The Program Specialist reviewed Individual #1's May 2026 Medication Administration Record (MAR) and identified that the frequency of administration for Lisinopril 20 mg tablet was not documented. The MAR was immediately corrected to reflect the prescribed frequency of administration as indicated on the current physician order and pharmacy-labeled container.
May 21, 2026 -- The Agency Nurse verified the accuracy of the medication record and confirmed that all required medication information was accurately reflected on the MAR.
May 29, 2026 -- Staff responsible for medication documentation received retraining regarding medication record requirements, including the requirement that the frequency of administration for each prescribed medication be accurately documented on the MAR. |
05/29/2026
| Implemented |
| 6500.136(a)(10) | At 3:20PM, Individual #1 had a prescription bottle of Lisinopril 20mg tab that was just filled on 4/26/26. The administration times of this medication is not listed on the May 2026 medication record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | May 21, 2026 -- The Program Specialist reviewed Individual #1's May 2026 Medication Administration Record (MAR) and identified that the administration times for Lisinopril 20 mg tablet were not documented. The MAR was immediately corrected to include the prescribed administration time(s) as indicated on the current physician order and pharmacy-labeled container.
May 21, 2026 -- The Agency Nurse reviewed and verified the accuracy of the medication record to ensure that all required medication information, including administration times, was accurately reflected on the MAR.
May 29, 2026 -- Staff #1 responsible for medication documentation received retraining regarding medication record requirements, including the requirement that administration times be clearly documented for each prescribed medication to ensure medications are administered as ordered. |
05/29/2026
| Implemented |
| 6500.136(a)(11) | At 3:20PM, Individual #1 had a prescription bottle of Lisinopril 20mg tab that was filled on 4/26/26. The diagnosis or purpose of this medication is not listed on the May 2026 medication record. | 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. | May 21, 2026 -- The Program Specialist reviewed Individual #1's May 2026 Medication Administration Record (MAR) and identified that the diagnosis or purpose for Lisinopril 20 mg tablet was not documented. The MAR was immediately corrected to include the diagnosis/purpose for the medication as identified in the physician order and medical record.
May 21, 2026 -- The Agency Nurse reviewed the medication record and verified that all required medication information, including the diagnosis or purpose for each medication, was accurately documented and consistent with the individual's current physician orders.
May 29, 2026 -- Staff #1 responsible for medication documentation received retraining regarding medication record requirements, including the requirement that the diagnosis or purpose for each medication, including PRN medications, be documented on the MAR. |
05/29/2026
| Implemented |
| 6500.136(b) | At 3:20PM, Individual #1 had a prescription bottle of Lisinopril 20mg tab that was filled on 4/26/26. This medication was not listed on the May 2026 medication record. Interviews revealed that Individual #1 was to stop taking Amlodipine 10mg tab and begin taking Lisinopril 20mg tab; Family Living Provider #1 followed the prescribers' orders, however logged the Lisinopril's administration under Amlodipine. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | April 21, 2026 -- The Program Specialist reviewed Individual #1's medication records and identified that following a physician-ordered medication change from Amlodipine 10 mg tablet to Lisinopril 20 mg tablet, the Medication Administration Record (MAR) was not updated to reflect the new medication. Although Family Living Provider #1 administered Lisinopril as prescribed, the administration was documented under the discontinued Amlodipine entry.
April 21, 2026 -- The MAR was immediately corrected to accurately reflect the current physician order, including the discontinuation of Amlodipine and the addition of Lisinopril. Documentation was updated to ensure that medication administrations are recorded under the correct medication entry at the time of administration.
April 21, 2026 -- The Agency Nurse reviewed the physician orders, pharmacy labels, and medication records to verify that all current medications were accurately transcribed and documented.
May 29, 2026 -- Staff #1 received retraining on medication administration documentation requirements, including the requirement that medication administration information be recorded on the MAR at the time the medication is administered and under the correct medication entry following any medication changes. |
05/29/2026
| Implemented |