| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | Two drop ceiling tiles in the home's laundry room were in disrepair. One ceiling tile had brown discoloration along two of its edges consistent with water damage, causing it to warp in the ceiling fixture. The other ceiling tile was crudely torn or cut in half to allow piping to come down from the ceiling and into the laundry room. This second ceiling tile also had a large, brownish discoloration consistent with water damage. | Floors, walls, ceilings and other surfaces shall be in good repair. | Laundry room ceiling tiles were replaced. Attachment # 29 |
03/18/2025
| Implemented |
| 6400.72(a) | Several windows in this home were missing window screens at the time of inspection: one window in the home's laundry room and two windows in the staff office. There were no window screens found elsewhere within the home that could be fit into these windows' frames if they were open and in use; therefore, these windows were incapable of being securely screened. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Window screens was placed in the laundry room and 2 staff room windows. Attachment # 30 and # 31 |
03/18/2025
| Implemented |
| 6400.141(a) | Individual #1's two most recent Annual Physical Examinations occurred on 11/18/2023 and 01/22/2025, more than one year apart. This individual did not receive a Physical Examination annually as required. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #1 physical was scheduled for 11/14/2024, but individual #1 refused to go to the appointment. A refusal form will be completed and signed on 2/26/2025. Individual's physical was rescheduled and completed on 1/23/2025. Individual #1 does have a desensitization plan regarding his refusal of medical appointments and is prescribed an anxiety medication to help him participate in his medical appointments. Attachment # 32 and # 33 |
03/25/2025
| Implemented |
| 6400.142(a) | The most recent record of a dental examination and cleaning found within Individual #1's Individual Record was dated 02/15/2024. Record of a more recent dental examination and cleaning was not found within the Individual Record. When asked, the provider stated that an appointment was not scheduled for the individual in the 2025 calendar year because the individual's dentist recommended that dental examinations and cleanings occur once every two years; however, there is no exception to the regulatory requirement that a dental examination and cleaning occur for individuals annually. This individual did not receive a dental examination and cleaning annually as required. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Staff contacted the dentist regarding their recommendations, and they faxed over a statement stating that they are recommending him to be seen every 2 years. Attachment # 34 |
03/25/2025
| Implemented |
| 6400.143(a) | There was documentation of Individual #1's refusal of an appointment for a Physical Examination on 11/14/2024; however, this document was dated 02/26/2025, long after the appointment occurred. First, the refusal was not documented in the Individual Record at the time of occurrence. Second, there were no records of additional attempts to train the individual about the need for health care occurring between the refused appointment on 11/14/2024 and the Annual Physical Examination that occurred on 01/22/2025. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | Staff will follow the desensitization plan for the individual #1 and will make sure Refusal forms are completed during the day of the refused appointment. Attachment # 35 |
03/25/2025
| Implemented |
| 6400.144 | At the time of inspection, the Over the Counter (OTC) medications recommended by Individual #1's Primary Care Physician (PCP) were not located 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.
| OTC medication list was removed from the individual's records and will not be filled out with their annual physicals. |
03/25/2025
| Implemented |
| 6400.181(e)(14) | In an area designated for water safety, Individual #1's most recent Individual Assessment, dated 02/26/2025, stated that the individual "···understands water safety and is safe around large bodies of water" and that the individual "···does not know how to swim and needs supervision around large bodies of water." As these two statements are contradictory, the individual's abilities in this domain were not appropriately assessed by the Program Specialist. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | Staff updated Individual's #1 assessment to better reflect his understanding of water safety and not being able to swim. Attachment # 36 |
03/25/2025
| Implemented |
| 6400.52(c)(6) | Staff #1 works directly with individuals. Per documentation in the Staff Record, Staff #1 did not receive training in the following area during the 2023/2024 training year: Implementation of the individual plan if the person works directly with an individual. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | Staff receive ISP training during New Employee Orientation. See attachment #21 |
02/28/2025
| Implemented |
| 6400.166(a)(4) | According to the Chapter 6400 Regulatory Compliance Guide (RCG), Over the Counter (OTC) medications must be recorded on the Medication Administration Record (MAR). The Over the Counter (OTC) medications recommended by Individual #1's Primary Care Physician (PCP) were not recorded on the individual's February 2025 MAR. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | OTC medication list was removed from the individual's records and will not be filled out with their annual physicals. |
03/25/2025
| Implemented |