| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.111(f) | Fire extinguishers were inspected 4/2/2024 and not again until 4/4/2025. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | Kint Corp. is the designated vendor for annual fire extinguisher inspections across all programs. We have provided them with detailed information regarding our regulatory requirements and will coordinate inspection scheduling cycles to ensure full compliance. Kint Corp. has confirmed that they have updated our inspection date in their system accordingly. Attachment #2 |
08/22/2025
| Implemented |
| 6400.144 | Individual #1 has a PRN medication, Dulcolax (Bisacodyl) 5mg, with instructions to administer 2 tablets if they go 48 hours without a bowel movement. Individual #1 had a bowel movement on 7/21/2025 at 7:18am, then not again until 7/23/2025 at 7:00pm. This timeline exceeded 48 hours and Dulcolax was not administered. Individual #1 had a bowel movement on 7/25/2025 at 4:00pm, then not again until 7/28/2025 at 5:00am. This timeline exceeded 48 hours and Dulcolax was not administered.
· Individual #1 has a PRN medication, Dulcolax (Bisacodyl) 5mg, with instructions to administer 2 tablets in they go 48 hours without a bowel movement. Individual #1 had a bowel movement, per the Bowel Movement Record on 7/28/2025 at 9:30pm. Per the Bowel Movement Record, Dulcolax was administered to Individual #1 on 7/30/25 8:45am - approximately 35 hours after the last bowel movement (not the required 48). Additionally, the July 2025 MAR shows another administration of Dulcolax on 7/30/2025 at 8:45pm, yet he previously had received Dulcolax at 8:45am and it is recorded there was a bowel movement on 7/30/2025 at 1:30pm. | 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.
| At this program, staff did not correctly calculate the required timeframe for administering medication following the absence of a bowel movement. As a result, the individual did not receive medication within the designated protocol window.
To support staff in accurately calculating and documenting this, we are providing two updated resources:
1. Revised Bowel Movement Tracking Chart A new line has been added: ¿Next BM date/time due by:¿ Staff will use this field to record the exact date and time by which a bowel movement must occur. If no bowel movement is documented by that time, medication must be administered per protocol.
2. Bowel Protocol Timeline Quick Reference This reference tool outlines the required medication administration timeframes at 24, 36, and 48 hours. It is designed to help staff compute and enter the correct ¿due by¿ date/time on the Tracking Chart.
Both of the above are submitted as Attachment #3. |
09/01/2025
| Implemented |
| 6400.34(a) | Individual #1 was not informed of their rights related to regulations 31a -- 31g on the Individual Rights and Responsibilities signed on 11/15/2024. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | On 8/19/25, the Individual Rights form updated to include items 31a through 31gwas signed by both the individual and their Guardian. A corresponding Checklist has been developed to accompany the Annual Packet distributed each November. Upon return, the Residential Secretary will review each packet for completeness and address any areas requiring follow-up |
08/19/2025
| Implemented |
| 6400.165(e) | At the time of the inspection (8/6/2025) a medication was noted on Individual #1's August 2025 Medication Administration Record (MAR) for PRN usage of Dexamethasone SP 4mg. This medication was discontinued on 6/8/2025 per doctor's orders, but it was not removed from the MAR. | Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received. | It was identified that the Acting Supervisor utilized a previously saved MAR from the computer, resulting in the prior months medication information being carried over into the current month without a thorough review against the individuals current medication orders. Although the individual did not receive any discontinued medications, this oversight underscores the need for strengthened review protocols. |
09/01/2025
| Implemented |
| 6400.166(b) | At the time of the physical site inspection (8/6/2025 at approximately 10:00am), the August 2025 Medication Administration Record recorded that Esomeprazole 40mg was administered to Individual #1 on 8/6/2025 at 6:05am, however there was no name or initials of the staff who administered the medication. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Staff have been retrained on the 15 Steps of Medication Administration. The Training Sign-In Sheet has been submitted separately for documentation. Attachment #6. As part of our ongoing plan to reduce medication errors, Supervisors have been reviewing the 15 Steps during monthly staff meetings to reinforce best practices, and will continue to do so. |
08/19/2025
| Implemented |