| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Individual #1 is prescribed Lamotrigine 25 mg with instructions to take 1 tablet by mouth daily. On 9/4/25 at 11:04 AM, this medication bottle was found with all of Individual #1's other daily medications. The above medication was neither listed on Individual #1's September 2025 Medication Administration Record, nor initialed by staff to show its daily administration. The bottle for Individual #1's prescribed, Lamotrigine 25 mg, had a filled date of 8/13/25 and currently had 21 tablets left. This medication would have needed to have been administered twice daily for 22 consecutive days, which would have left 16 tablets remaining in the bottle had it been administered as directed. Therefore, this medication error regarding Individual #1's prescribed, Lamotrigine 25 mg, occurred over more than one consecutive administration. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | The medication that is to administered to our individuals shall be closely monitored. In the event that the individual is new to our agency, all medication will be cataloged and placed in its perspective medication log. DHS staff will closely monitor the amount of medication that are in bottles and |
10/31/2025
| Implemented |
| 6400.106 | The home had the furnace inspected and cleaned on 7/2/24, and then again on 7/31/25. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| The Site Monitor and Supervisor will schedule annual furnace cleaning within the most recent year and confirm with the Director if any issues arise from the the last years cleaning. |
10/31/2025
| Implemented |
| 6400.107 | On 9/4/25 at 11:33 AM, a portable electric space heater was located in the basement of the home. | Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including staff rooms.
| All space heaters will be removed from our CLA homes. |
10/31/2025
| Implemented |
| 6400.141(a) | Individual #1 was admitted to the agency for emergency respite care on 7/17/25. As of 9/5/25, Individual #1 has not had a physical examination completed. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | All new individuals will have a physical examination performed they are admitted into the CLA program. |
10/31/2025
| Implemented |
| 6400.15(b) | The agency used the Department's licensing inspection instrument modified in June 2018 to complete the self-assessment for this home. The current licensing inspection summary instrument for the community homes regarding individuals with intellectual disability or autism regulations was promulgated in February 2020. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | DHS has removed all 2018 licensing inspection forms and replaced them with the 2020 version. This will allow DHS to conduct a more concise review of the regulatory compliance for our individuals. |
10/31/2025
| Implemented |
| 6400.32(r)(4) | On 9/4/25 at 11:27 AM, the inside of Individual #1's bedroom door was equipped with a push button locking mechanism. The outside of Individual #1's bedroom door did not have a mechanism to unlock the door in order to allow easy and immediate access by the individual and staff persons in the event of an emergency. On 9/4/25 at 11:27 AM, the inside of Individual #2's bedroom door was equipped with a push button locking mechanism. The outside of Individual #2's bedroom door did not have a mechanism to unlock the door in order to allow easy and immediate access by the individual and staff persons in the event of an emergency. On 9/4/25 at 11:27 AM, the inside of Individual #3's bedroom door was equipped with a push button locking mechanism. The outside of Individual #3's bedroom door did not have a mechanism to unlock the door in order to allow easy and immediate access by the individual and staff persons in the event of an emergency. | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. | All doors within the home will be changed in order to allow our individuals the opportunity to exit their bedrooms. We have a contractor that will be providing the work to complete the necessary changes to the locks. |
10/31/2025
| Implemented |
| 6400.166(a)(4) | Individual #1 is prescribed Lamotrigine 25 mg with instructions to take 1 tablet by mouth daily. On 9/4/25 at 11:04 AM, the name of this medication was not listed on their September 2025 Medication Administration Record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | All medication will be listed on their medication records with the correct individuals name on it as well the name of the medication and the dosage and other pertinent information. |
10/31/2025
| Implemented |
| 6400.166(a)(5) | Individual #1 is prescribed Lamotrigine 25 mg with instructions to take 1 tablet by mouth daily. On 9/4/25 at 11:04 AM, the strength of this medication was not listed on their September 2025 Medication Administration Record. Individual #1 is prescribed Trazadone 100 mg tablet with instructions on the medication label to take half tablet (50 mg) at night for insomnia. However, Individual #1's September 2025 Medication Administration Record read: "Trazadone 50 mg--Take ½ tablet by mouth at night for insomnia." | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | All medication administration forms will be completed in their entirety and have the correct name of the medication along with the dosage and times to be administered. |
10/31/2025
| Implemented |
| 6400.166(a)(6) | Individual #1 is prescribed Lamotrigine 25 mg with instructions to take 1 tablet by mouth daily. On 9/4/25 at 11:04 AM, the dosage form for this medication was not listed on Individual #1's September 2025 Medication Administration Record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | All medication administration records shall be kept up to date and all medications that are administered to our individuals are correct and that the dosages be visible and easily viewed by staff. |
10/31/2025
| Implemented |
| 6400.166(a)(7) | Individual #1 is prescribed Lamotrigine 25 mg with instructions to take 1 tablet by mouth daily. On 9/4/25 at 11:04 AM, the dose for this medication was not listed on their September 2025 Medication Administration Record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | All medication charts will be up to date and the correct dosage of such medication will be in these charts. In addition, the correct medication will also be on the medication forms. |
10/31/2025
| Implemented |
| 6400.166(a)(8) | Individual #1 is prescribed Lamotrigine 25 mg with instructions to take 1 tablet by mouth daily. On 9/4/25 at 11:04 AM, the route of administration for this medication was not listed on their September 2025 Medication Administration Record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | All incoming and current medication will be cataloged and placed in the individuals medication administration form. Staff will also update the forms when a medication is added or subtracted from the medication form and how the medication is administered. |
10/31/2025
| Implemented |
| 6400.166(a)(9) | Individual #1 is prescribed Lamotrigine 25 mg with instructions to take 1 tablet by mouth daily. On 9/4/25 at 11:04 AM, the frequency of administration for this medication was not listed on their September 2025 Medication Administration Record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | All medication logs will provide the frequency of the distribution of the medicine for our individuals. Staff will adhere to the prescription and the Doctors order along with the pharmacist records. |
10/31/2025
| Implemented |
| 6400.166(a)(10) | Individual #1 is prescribed Lamotrigine 25 mg with instructions to take 1 tablet by mouth daily. On 9/4/25 at 11:04 AM, the administration time for this medication was not listed on their September 2025 Medication Administration Record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | All medication administration forms will have the correct medication and the times that the medication will be administered. These will be updated when any medication is changed. |
10/31/2025
| Implemented |
| 6400.166(a)(11) | Individual #1 is prescribed Metformin HCL 1000 mg tablet. Their September 2025 Medication Administration Record for this medication did not indicate its diagnosis or purpose. Individual #1 is prescribed Lamotrigine 25 mg with instructions to take 1 tablet by mouth daily. On 9/4/25 at 11:04 AM, the diagnosis or purpose for this medication was not listed on Individual #1's September 2025 Medication Administration 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. | All medication and the need for the medications will be present in the medication logs. In addition, the the diagnosis and reason for the medication will be present in the medication administration forms. |
10/31/2025
| Implemented |
| 6400.166(a)(15) | Individual #1 is prescribed Hydroxyzine HCL 25 mg with instructions on the medication label that state, "Take 2 tablets by mouth at bedtime. Can also take 1 tablet before getting injections." Individual #1's September 2025 Medication Administration Record states, "Take 2 tablets by mouth at bedtime," regarding this medication and does not include the special instructions, "Can also take 1 tablet before getting injections." | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Special precautions, if applicable. | All medication recommendations will be followed. In the event that any special instructions for particular medications are present the staff will administer them accordingly. |
10/31/2025
| Implemented |
| 6400.166(b) | Individual #1 is prescribed Clonazepam 0.5 mg tablet with instructions to take one tablet by mouth twice a day for mood. This medication was not initialed as having been administered on 9/3/25 at the 8:00 PM on Individual #1's September 2025 Medication Administration Record. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | All medication administration records will be kept up to date. Staff will initial when administering medication in the proper space and review these records on a regular basis. |
10/31/2025
| Implemented |
| 6400.167(a)(1) | Individual #1 is prescribed Lamotrigine 25 mg with instructions to take 1 tablet by mouth daily. On 9/4/25 at 11:04 AM, this medication bottle was found with all of Individual #1's other daily medications. The above medication was neither listed on Individual #1's September 2025 Medication Administration Record, nor initialed by staff to show its daily administration. The bottle for Individual #1's prescribed, Lamotrigine 25 mg, had a filled date of 8/13/25 and currently had 21 tablets left. This medication would have needed to have been administered twice daily for 22 consecutive days, which would have left 16 tablets remaining in the bottle had it been administered as directed. | Medication errors include the following: Failure to administer a medication. | All current medications that need to administered to our individuals will be administered at the time and date listed on the prescription. No staff will deviate from such protocol. |
10/31/2025
| Implemented |