| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.81(k)(5) | On 8/27/2025 at 1:18pm, Individual #2's bedroom was observed without a closet or wardrobe space with clothing racks and shelves. The only closet or wardrobe available to individual #2 was located in the hallway outside of their bedroom. According to Program Manager #1, Individual #2's assessment and ISP, last updated 8/18/2025, did not indicate that it was the individual's choice to not have a closet or wardrobe in their bedroom. | In bedrooms, each individual shall have the following: Closet or wardrobe space with clothing racks and shelves accessible to the individual. | A new closet / wardrobe was ordered for the person supported. |
10/01/2025
| Implemented |
| 6400.181(a) | Individual #1's had an annual assessment completed on 2/7/2024, and then again on 8/25/2025. This exceeds the annual requirement. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Mainstay Life Services understands that 6400.181(a) was out of compliance and cannot be brought back into compliance. However, Mainstay Life Services will implement systemic and procedural actions to prevent recurrence. |
10/01/2025
| Implemented |
| 6400.166(a)(10) | On 8/27/2025 at 12:57pm, the following medications prescribed to Individual #1 had an administration time of 8:00am on the medication blister package and 10:00am on the August 2025 medication administration record: Allpurinol Tab 100mg, Aspirin Low CHW 81mg, Folic Acid Tab 1mg, Furosemide Tab 20mg, Jardiance TAB 25mg, Losartan pot tab 25mg, Metformin Tab 500mg ER, Methotrexate Tab 2.5mg, and Metoprol Suc Tab 100mg ER. [Repeat violation 9/4/24, et. al.] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | The Medication Administration Record (MAR) was rectified. |
10/01/2025
| Implemented |
| 6400.166(a)(11) | On 8/27/2025 at 12:56pm, Methotrexate Tab 2.5mg prescribed to Individual #1 had a diagnosis or purpose of the medication of "rash" on the pharmacy medication label and "arthritis" on the August 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. | The Medication Administration Record (MAR) was rectified. |
10/01/2025
| Implemented |
| 6400.181(f) | Individual #1's annual plan meeting was held on 1/30/2025. There was no documentation provided that a current assessment was provided prior to the meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Mainstay Life Services understands that 6400.181(f) was out of compliance and cannot be brought back into compliance. However, Mainstay Life Services will implement systemic and procedural actions to prevent recurrence. |
10/01/2025
| Implemented |