| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | At 10:27AM on 5/28/2026, two unlabeled, plastic spray bottles reportedly containing rubbing alcohol were in the cupboard in the kitchen of the home. At 10:34AM, two unlabeled, plastic spray bottles reportedly containing rubbing alcohol were on the shelf at the landing of the stairs leading to the basement of the home. | Poisonous materials shall be stored in their original, labeled containers. | Upon receipt of the deficiency notice, BrightPath Human Services immediately removed all non-labeled poisonous materials from the home. These items were placed in trash bags, after being dumped down the drain, transported to the regional office, and properly disposed of in the designated dumpster. |
06/12/2026
| Implemented |
| 6400.67(b) | At 10:36AM on 5/28/2026, what appeared to be rain water was entering the home onto the floor from the exit door in the basement. At 10:37AM, there was no cover on the drain outside the exit door leading from the basement of the home posing a tripping hazard. At 10:38AM, an extension cord was lying along the middle of the basement floor plugged into a dehumidifier near a drain with the drain cover next to the drain posing a slipping and tripping hazard. At 10:39AM, there was no cover on the floor drain on the right side of the basement posing a tripping hazard. At 10:39AM, there was a six-foot by two-foot area water on the floor that appeared to entered from the wall on the right side of the basement of the home. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Upon receipt of the deficiency notice, BrightPath Human Services contacted Rainbow Restoration to schedule an evaluation of the water leak affecting the basement door and wall. The evaluation is scheduled for June 15, 2026. Any repairs identified as necessary to correct the leak will be completed following the assessment and recommendations provided during the appointment. The Executive Director will be responsible for ensuring this work is completed and the issue is resolved. |
06/15/2026
| Implemented |
| 6400.71 | The provider agency is utilizing a cellular phone in lieu of a landline telephone service. At 10:21AM on 5/28/2026, the home address and the telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not on or by the cellular device. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| Upon receipt of the deficiency notice, BrightPath Human Services immediately corrected the issue by placing the home's address and required emergency contact numbers on the back of the cellular phone used within the residence. This corrective action was completed on June 3, 2026, bringing the home back into compliance with the regulation. |
06/12/2026
| Implemented |
| 6400.101 | At 10:41AM on 5/28/2026, there was a two-foot by ten-inch, wooden gate with a slide lock at the top left side on the front porch obstructing the egress from the home. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Upon receipt of the deficiency notice, BrightPath Human Services contacted a maintenance vendor to remove the gate located on the front porch. The gate was removed on June 11, 2026, restoring unobstructed egress from the residence and bringing the home into compliance with Regulation 6400.101. |
06/12/2026
| Implemented |
| 6400.106 | The home had a furnace inspection and cleaning completed on 10/1/2024 and then again on 10/30/2025. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| Upon receipt of the deficiency notice, BrightPath Human Services verified that the furnace inspection was completed on 10/30/2025 and not due again until 10/30/2026. |
06/12/2026
| Implemented |
| 6400.181(e)(1) | Individual #1's assessment, completed 6/29/2025, did not include Individual #1's preferences. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | Upon receipt of deficiency, the Program Specialist added the Functional Strengths, needs and preferences of individual #1. This was completed on 6/11/2026. Additionally, a full audit of all individuals receiving services by BrightPath Human Services in regard to 6400.181(e)(1) will occur and be completed by 6/30/2026. Any issues of non-compliance will be fixed. The Clinical Manager is responsible for the completion and oversight of this task. |
06/12/2026
| Implemented |
| 6400.46(d) | Program Specialist #1, date of hire 5/7/2025, has not completed training in Heimlich techniques and cardio-pulmonary resuscitation. Direct Service Worker #2, date of hire 11/25/2024, did not complete initial training in Heimlich techniques and cardio-pulmonary resuscitation until 9/15/2025. [Repeat Violation, 7/16/2025] | 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. | Upon receipt of the deficiency notice, the Program Specialist completed CPR and First Aid certification training on June 1, 2026, bringing the position into compliance with Regulation 6400.46(d). |
06/12/2026
| Implemented |
| 6400.163(h) | At 11:15AM on 5/28/2026, Individual #1's prescribed medication, Cetirizine, with an expiration date of 5/1/2026 was in Individual #1's medication box. At 11:17AM, Individual #1's prescribed medication, Acetaminophen with an expiration date of 3/3/2026 was in Individual #1's medication box. At 11:18AM, Individual #1's prescribed medication, Ondansetron with an expiration date of 3/5/2026 was in Individual #1's medication box. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Upon receipt of the deficiency notice, all expired medications were immediately removed from the home and destroyed in accordance with BrightPath Human Services policies and procedures. This corrective action was completed on May 28, 2026, bringing the home into compliance with Regulation 6400.163(h). |
06/12/2026
| Implemented |
| 6400.166(b) | Individual #1's 8:00PM medications were not initialed as administered on 5/27/2026. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Upon receipt of the deficiency notice, the Residential Services Director conducted a review to determine whether a medication error had occurred. The review concluded that no medication error had taken place; rather, the issue involved a documentation error resulting from staff failing to properly document medication administration. The missing documentation was completed by the responsible staff member on May 29, 2026, bringing the record into compliance with Regulation 6400.166(b). |
06/12/2026
| Implemented |