| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(c) | (Repeat from 10/22/24) The self-assessment completed on 10/20/25 identified the following violations: 142a and 143a. No plans of corrections were documented. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| Immediate Actions: 11/13/2025- The Central Region Operations Director was trained by the COO on their responsibility that self-assessment results and a written summary of corrections made shall be complete and kept by the agency for at least one year.
11/13/2025- A training record was signed indicating their attendance and understanding. (Attachment #1) QA Associate will continue to complete self-assessments per the regulations and regulatory compliance guide to ensure all regulations are answered and a written summary of corrections is completed if a regulation is in violation.
11/13/2025- The Self-Assessments were updated with a plan of correction for each documented deficiency and all supporting documents which ensures the self-assessment was completed correctly. All regulations were reviewed and documented for each self-assessment completed. This also verifies a written summary of corrections were completed for all regulatory violations. (if applicable) |
11/13/2025
| Implemented |
| 6400.22(d)(1) | Individual #1's Visa card transaction record is not accurate, as the total amount of the purchases versus the balances shown do not match.
Additionally, there is a receipt provided from 06/14/25 for Puff N Bean in the amount of $55.50 that is not shown on the transaction record for the Visa card; therefore, the entirety of the transactions does not appear to be available. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | Immediate Actions: The Program Manager was contacted and the transaction ledger for the Visa card for Individual #1 was sent to the Central Region Operations Director on 10/27/25. The transaction dated for 6/14/25 is recorded on the ledger and the receipt is attached to the ledger. Attachment #2 Attachment #3
The Program Manager was retrained by the Central Region Operations Director on 10/30/25, on regulation 6400.22(d)(1).
The Program Manager was retrained on making certain that all financial records are available at all times and all transactions are entered into the electronic database.
Attachment# 4 |
10/30/2025
| Implemented |
| 6400.144 | (repeat violation from the 10/20/24) Individual #1 is prescribed Milk of Magnesia Suspension 400 mg, take 30 ml once daily as needed. There is not a protocol in place for when this medication is to be administered for constipation. | 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.
| Immediate Action: The Program Manager was trained by the Central Region Operations Director on 10/30/25 on medication administration procedures and checking that all medications are correct and a protocol for the medication is in writing before acceptance. Attachment #5
The prescribing doctor was notified for a protocol for the Milk of Magnesia on 10/27/25 and again on 11/14/25. |
10/30/2025
| Implemented |
| 6400.181(d) | For individual #1's 03/02/25 initial assessment, the Program Specialist did not sign and date the assessment. | The program specialist shall sign and date the assessment. | Immediate Action: The Program Specialist was trained by the Central Region Operations Director on 10/30/25 on regulation 6400.181(d), signing the assessment upon completion. Attachment #7
Signed Assessment attachment #8 |
10/30/2025
| Implemented |
| 6400.181(e)(3)(iv) | For individual #1's 08/02/25 annual assessment, it does not identify the individual's personal needs with or without assistance; the assessment only states "individual is not happy about their low sodium restrictive diet." | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal needs with or without assistance from others. | Immediate Action: The Program Specialist was retrained on regulation 6400.181(e)(3)(iv) by the Central Operations Director on 10/30/25. Attachment #9
The Program Specialist created an Addendum to the Assessment that includes Individual #1's personal needs with or without assistance which was sent to the Supports Coordinator on 11/12/25. Attachment #10, Attachment #11 |
11/12/2025
| Implemented |
| 6400.166(a)(5) | Individual #1 is prescribed Lisinopril and on 03/12/25, the medication was increased to 30 mg, with instructions to take 20 mg, 1 and a half tablets daily. The March and April 2025 MAR's do not identify that the strength of the medication is 30 mg. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | Immediate Action: The Program Manager was trained by the Central Region Operations Director on 10/30/25 on the medication administration procedure to make certain that the label matches the MAR. Attachment #5
Correction was made to the current MAR to reflect the administered strength of the medication. Attachment #6 |
10/30/2025
| Implemented |
| 6400.186 | Individual #1's 08/02/25 annual assessment states that the individual receives $80 a month in spending money and the individual is not being given this monthly allotment. | The home shall implement the individual plan, including revisions. | Immediate Action: The Program Specialist was retrained on regulation 6400.186 by the Central Operations Director on 10/30/25. Attachment #12
The Program Specialist created an Addendum to the Assessment that included the updated fianacial information for Individual #1. A copy of the Addendum was sent to the Supports Coordinator on 11/14/25. Attachment #13, Attachment #14 |
10/30/2025
| Implemented |