| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | Individual # 2's top left dresser knob was missing during the physical site walk through. | Floors, walls, ceilings and other surfaces shall be in good repair. | The dresser was repaired on 12.17.25 by placing two new knobs on the top drawer. See attachment #1 for photo of corrected dresser. All Site Supervisors checked the furniture and internal surfaces of all other sites to ensure that all furniture and surfaces are in good repair. An email was sent on 12.14.25 (attachment #9) to all Site Supervisors and Program Managers reviewing the regulation and asking for all homes to be checked to ensure floors, walls, ceilings and other surfaces are in good repair. All supervisors had to respond to state if any problems areas were found or if homes were inspected and had no issues. For any concerns, work orders were submitted for repair. |
01/30/2026
| Implemented |
| 6400.82(f) | There was no soap in the laundry area bathroom during the physical site walk through. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Clarification of this regulation was provided to LPN that removed the soap from the bathroom. This information was present to the LPN by the Regional Director. The LPN knew that poisons are to be locked in the home so she removed the soap from the bathroom area as a precaution prior to the inspector arriving for the home's visit. She now knows that the homes only purchase non-toxic soap and that each bathroom and toilet area must have soap available. All homes were checked to ensure that soap is available in the bathrooms of all homes. |
12/15/2025
| Implemented |
| 6400.144 | Individual # 1 is prescribed Valtoco 15 mg nasal spray PRN which is to be given for seizures lasting longer than 7 minutes. Valtoco is to be given at 7 minutes and After 17 minutes of continue seizure, staff are to call 911. On 09/06/25, Individual # 1 had a seizure at 2:25pm but did not receive the Valtoco until 2:53 pm. | 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.
| The staff person who made this error no longer works for Clarvida, so we were unable to provide her specific training. The other staff at this home home received re-training on the seizure protocol. See attachment #12. |
12/17/2025
| Implemented |
| 6400.186 | Individual # 1's ISP dated 11/20/25 reads "STAFF WILL CHECK ON INDIVIDUAL #1 EVERY 15 MINUTES AND AS NEEDED DUE TO THEIR SEIZURE ACTIVITY WHEN THEY CHOOSE TO SPEND ALONE TIME IN THEIR BEDROOM AND THE COMMON AREAS OF THEIR HOME. WHEN Individual # 1 IS IN THEIR BEDROOM SLEEPING, STAFF WILL CHECK ON Individual # 1 HOURLY." Staff reported that there is not a tracking document to ensure that 15-minute checks are occurring nor the hourly checks. Additionally, the plan reads "Individual # 1 WEARS A BI-PAP EVERY NIGHT FOR SLEEP APNEA. STAFF CHECKS THE BI-PAP TWO TIMES THROUGHOUT THE NIGHT TO ENSURE IT IS WORKING PROPERLY. ALL STAFF ARE TRAINED ON THE CARE OF THE MACHINE UPON HIRE. There is no tracking documentation that Staff are checking the BI-PAP twice per night. | The home shall implement the individual plan, including revisions. | Individual #1 safety checks - 15 minutes when alone in room during awake hours and hourly during sleep hours.
Individual #1 Bi-Pap did not need to be checked two times per night. That information should have been changed in the plan prior to now. The SC was contacted to correct the information so that the Bi-Pap is checked at bedtime each night (see attachment #14). That documentation is in place and checks have occurred. (attachment #15) |
01/12/2026
| Implemented |