| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(f) | At the time of inspection, two trash receptacles belonging to this home were at the home's curbside at the end of the driveway. The lids of both of these trash receptacles were open, with additional bags of trash piled on top of them. These trash receptacles were uncovered and susceptible to penetration by rodents or insects. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | Staff will ensure trash is picked up on a weekly basis to eliminate overflowing which prevents the lids to be shut properly. If another trash can is needed to eliminate overflowing, Threshold will make a purchase of a new trash can. Attachment # 16 |
02/28/2025
| Implemented |
| 6400.72(a) | At the time of inspection, one window in the home's kitchen was missing a window screen. As there was no window screen found elsewhere in the home that could be fit into this window's frame if it should be opened, the window was incapable of being securely screened. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Window screen was placed in the kitchen window. Attachment # 17 |
03/04/2025
| Implemented |
| 6400.142(a) | Per the Individual Record, Individual #1's two most recent dental examinations and cleanings occurred on 10/13/2023 and 11/12/2024, more than one year apart. This individual has not received 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. | Individual #1 dental exam was scheduled for 10/16/2024 but was cancelled due to Individual #1 eating breakfast prior to the appointment. Individual #1 next dental appointment is scheduled for 11/14/2025. Attachment # 18 |
03/25/2025
| Implemented |
| 6400.144 | Individual #1's 06/21/2024 Physical Examination notes that the individual requires a Prostate Specific Antigen (PSA) screening annually. Individual #1's Individual Record included a PSA screening that was dated 09/12/2023. There was no record of a more recent PSA screening found within the Individual Record. The medical provider's recommendation regarding the frequency of PSA screenings was not followed by the Provider.
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.
| Staff scheduled Individual #1 annual prostate exam/ PSA on 3/28/2025. Attachment # 19
*OTCs will be obtained, when necessary, from the physician and the OTC lists have been discontinued. * KS |
03/25/2025
| Implemented |
| 6400.151(a) | The two most recent physical examinations found within Staff #1's Staff Record were dated 01/06/2022 and 01/25/2024---more than two years apart. This staff did not receive a physical examination at least once every two years as required. | 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. | Ensure that staff complete pre-employment physical exams and every two years based on the last physical exam date. Attachment #20 |
03/06/2025
| Implemented |
| 6400.46(d) | Per documentation in the Staff Record, Staff #1's most recent trainings in first aid, Heimlich techniques, and cardio-pulmonary resuscitation (CPR) occurred on 03/31/2022 and 06/05/2024. The interim between these two trainings exceeded both the annual requirement under this Chapter and the alternative two-year renewal requirement issued by the training organization. This staff did not receive training in these areas at the required frequency. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Train all staff upon hire and every two years based on the certification date. Attachment # 21 |
01/01/2025
| Implemented |
| 6400.52(a)(1) | Per documentation in the Staff Record, Staff #1 completed only 17.95 hours of training during the 2023/2024 training year. This fell short of the 24 hours of annual training required for direct service workers. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | Ensure that the annual training plan exceeds 24 hours of training offered. Attachment #21 |
01/01/2025
| 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. Attachment # 21 |
03/28/2025
| Implemented |
| 6400.165(g) | Individual #1 takes prescription medications to treat the symptoms of psychiatric illness. Per the individual record, the individual's psychotropic medications were reviewed on the following dates: 01/31/2024, 07/25/2024, and 10/24/2024. There were no records of other psychotropic medication reviews occurring. This individual's psychotropic medications have not been reviewed at least once every three months as required during the review period. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Individual #1 medication management appointment was on 1/23/2025 and the next appointment is scheduled for 4/22/2025. Attachment # 22 |
03/25/2025
| 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 |