|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | At 10:00 AM on 2/11/26, the interior of the microwave had various brownish food splatters and particles. In addition, the finish along the lower frame surrounding the glass of the microwave's interior door was delaminating. At 10:06 AM, laying on the only windowsill in Individual #1's bedroom were seven dead insects. In addition, the slats of window blinds of this window were coated in with a layer of dust and debris. | Clean and sanitary conditions shall be maintained in the home. | A new microwave was requested on 2/11/26 and delivered on 2/12/26. The windowsill was cleaned on 2/11/26. The blinds were cleaned on 2/16/26 and new blinds were ordered on 2/16/26. |
03/12/2026
| Implemented |
| 6400.181(e)(12) | Individual #1's current assessment, completed 8/25/25, did not include recommendations for specific areas of training, programming, and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The recommendation section of Individual #1's assessment was updated to include specific areas of training, programming, and services on 2-17-26. The updated assessment was sent to all team members on 2-17-26 as evidenced by the critical exchange form. |
03/12/2026
| Implemented |
| 6400.166(a)(15) | At 11:01 AM on 2/11/26, Individual #1's February 2026 Medication Administration Record did not include the special precautions for the following prescribed medication and read accordingly on their corresponding medication labeled containers: "Humalog Kwik Pen 100 Units/ML---Inject subcutaneously 10 minutes before meals on non-workdays: B-12, L-14, D-16 units. On workdays: B-4, L-6, D-7 units" with special precautions to "Discard unused portion after 28 days. If you drink alcohol, discuss the safe use of alcohol while taking this medication with healthcare professional. Refrigerate unopened cartridges or pens. Once in use, do not refrigerate. Store the cartridge or pen in use at room temperature"; "Lantus Solostar 100 Unit---Inject 46 units subcutaneously at bedtime" with special precautions, "If you drink alcohol, discuss the safe use of alcohol while taking this medication with healthcare professional. Refrigerate the unopened product. May store at room temperature after opening for use. Once product is opened, discard unused medication after the number of days noted on product package [28 days]"; and "Ozempic 2 MG Dose (8 MG/ 3M)---Inject 2 MG subcutaneous once a week" with special precautions, "If you drink alcohol, discuss the safe use of alcohol while taking this medication with healthcare professional. Refrigerate the unopened product. May store at room temperature after opening for use. Once product is opened, discard unused medication after the number of days noted on product package [28 days]." | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Special precautions, if applicable. | The special precautions section on the back of the medication administration record for individual #1 was updated to include the full list of special precautions from the prescription container on 2-11-26. |
03/12/2026
| Implemented |
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.63(a) | On 4/5/23, at 10:43 AM, the hot water temperature at the kitchen sink measured 123.3 degrees Fahrenheit. | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | The landlord was contacted on 4/5/23 to request that the hot water tank be adjusted to reduce the water temperature. The temperature was rechecked on 4/6/23 and was 120 degrees at the kitchen sink. |
05/26/2023
| Implemented |
| 6400.214(b) | On 4/5/23, the following most recent records were not found at the home for Individual #1: a dental examination and a psychological evaluation. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| The most recent dental examination and psychological exam for individual #1 were obtained from the electronic medical record and placed into the binder locked in a cabinet in the home on 4/28/23. |
05/26/2023
| Implemented |
|
|