| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | The property record for individual #1 does not include a new shoe purchase made on 1/31/25 totaling $139.95. | 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. | Inventory for individual will be updated by: 07/15/25 |
08/31/2025
| Accepted |
| 6400.22(e)(3) | There were no receipts available for purchases over $15 from June 2024-December 2024 for individual #1. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | For individuals for whom Friendship Community is not a rep payee, copies of all receipts for purchases over $15 will be kept on file prior to return to the rep payee at the end of the calendar year by: 07/03/2025
Finance Team trained on regulation by: 06/20/2025 |
07/25/2025
| Accepted |
| 6400.151(a) | Staff person #9 had their annual physical 6/15/22 and not again until 6/18/24, which is outside of the required two year time frame. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | On June 13, 2024, Human Resources communicated to the employee, their manager, and program leadership that the required physical needed to be completed by June 15, 2024, and that the employee was not permitted to work until this requirement was met per existing agency policy. HR clarified that a TB test was not required for this particular employee to return given recent regulatory changes. Despite these efforts, the employee still worked a shift on June 17, 2024. The employee ultimately completed the physical on June 18, 2024.
Residential Managers received retraining on agency policy and regulation on 06/17/25 by Associate Director of Human Resources. |
07/15/2025
| Accepted |
| 6400.181(e)(11) | The 10/1/24 annual assessment for individual #1 states to see psychological evaluation attached however there is no psychological evaluation attached. | The assessment must include the following information: Psychological evaluations, if applicable. | Psychological evaluation will be attached to the assessment by: 07/04/2025 |
09/01/2025
| Accepted |
| 6400.166(b) | The provider switched from using paper MAR's to an eMAR system January 1st 2025. There were several instances where staff did not record the administration in the eMAR system immediately, but then documented the administration on the paper MAR with information that indicated medication administration is not being logged immediately.
The following are examples of medication administration documentation not happening immediately after the medications are given:
· On 5/7/25 and 5/28/25 staff documented on the paper MAR that the medication, Pantoprazole Sodium DR 40mg was administered on time at 7:30am but that they did not document in Tabula Pro (eMAR system) soon enough, unable to do so after 8:30am
· On 5/4/25 staff documented on the paper MAR that all the AM medications were administered at 8am but not signed on the Tabula.
· On 4/16/25 staff documented on the paper MAR that the medication Pentoxifylline ER 400mg was administered at noon but not recorded on Tabula due to oversight.
· On 3/31/25 staff documented on the paper MAR that the medication Pentoxifylline ER 400mg was administered at noon but forgot to document. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Create a survey asking team members about concerns/issues that they are having with Tabula Pro that are impeding them from documenting medication administrations. By: 07/30/25
Train Team Members on the importance of documentation with the time frames of medication administration. By: 07/30/25 |
09/01/2025
| Accepted |