| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.80(a) | At the time of the inspection 10/7/25, the walkway going from the driveway to the front door had several uneven areas where the top surface was worn away creating an uneven terrain and tripping hazard. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | Program Manager is still in the process of getting quotes for the work that needs to be completed. They had one quote by 10/25/25. |
11/28/2025
| Implemented |
| 6400.141(c)(3) | (Repeat from 10/15/24, 4/17/25 inspections) According to the immunization record individual #1 had a Tdap vaccine 1/30/13 and not again until 8/8/25 which is outside the recommended 10-year timeframe. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | TDaP was completed on 8/8/25.
LMH and Welligent immunizations were both updated by 10/23/25 so that this can be better tracked. |
11/28/2025
| Implemented |
| 6400.163(h) | (repeat from 10/15/24) At the time of the inspection on 10/7/25, the PRN loperamide was in individual #1's medication box and available despite the medication being discontinued by their physician on 4/8/25. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | PRN was removed from the home on 10/17/25. This is documented on a Welligent disposal form. |
11/28/2025
| Implemented |
| 6400.186 | (Repeat from 8/26/24 inspection) - On 8/15/25, the financial cash ledger showed a purchase for dinner in the amount of $60. No vendor receipt was available for this. There was a CSG handwritten receipt however the provider explained that the dinner did not actually cost $60 and the change was given directly to individual #1. Per the individual plan, the individual has been working on increasing their financial skills by working with fake money to learn the value of coins and bills. The assessment dated 6/17/25 also states that the individual requires assistance to appropriately make purchases and does not identify the amount of money the individual can handle on their own, if any. | The home shall implement the individual plan, including revisions. | Program Director retrained Program Supervisor, Manager and Specialist on definitions of financial independence for individuals vs budgeting needs for individuals (and what is required for receipts in both of these scenarios) on 10/13/25.
Program Specialist set up a team meeting to discuss with the team and Individual #1 how much money they can be responsible for at one time. Assessment was updated on 10/24/25. |
11/28/2025
| Implemented |