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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.104 | The home's Fire Department Notification Letter, dated 8/29/25, indicated that the two residing individuals require physical assistance to evacuate in the event of a fire. However, this letter did not provide the exact location of these individuals, as it read: "[These] [individuals] occupy separate bedrooms. In addition, this home's Fire Department Notification Letter, dated 8/29/25, did not include a description or diagram of the home's general layout in relation to the individuals' bedrooms. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| On 11/19/2025, evacuation needs and floor plans were sent in writing to the appropriate Fire Departments for all Twin Trees, Inc. sites. Notification included the exact location of the bedrooms of individuals who need assistance evacuating in the event of a fire. |
11/19/2025
| Implemented |
| 6400.141(c)(11) | Individual #1's current physical examination, completed on 8/5/25, did not include an assessment of their health maintenance needs, medication regimen, and the need for bloodwork at recommended intervals, as the corresponding field was left blank. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | On 11/18/2025, Program Director and CEO developed a new internal protocol on reviewing all individual's physical examinations. On 11/19/2025, Program Director trained Program Specialists and Agency Nurse on the change in internal protocol for review of all individual's physical examination forms to make sure they are completed in entirety. |
11/19/2025
| Implemented |
| 6400.181(e)(12) | Individual #1's current assessment, completed on 3/28/25, listed the following skill growth goals: "'[Individual #1] will walk about the house when [they] feel up to it; [Individual #1] will wipe off tables after meals; [Individual #1] will make a choice when presented with two options; [Individual #1] will relax in [their] room with some of [their] sensory items; [Individual #1] will use a napkin appropriately; [Individual #1] will participate in the fire drill monthly; [and] [Individual #1] will complete a simple task." However, Individual #1's current assessment did not include specific recommendations for areas of training, programming, and services in order to achieve these skill growth goals, as the corresponding fields were left blank. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | On 12/5/2025, Program Specialist updated Individual #1's assessment to include specific recommendations to meet goals listed in the assessment. |
12/05/2025
| Implemented |
| 6400.50(a) | Program Specialist #1's annual training for the 2024 calendar year did not document a trainer or source that conducted the sessions for the following required topics: person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships---completed on 12/4/24; the prevention, detection, and reporting of abuse, suspected abuse, and alleged abuse, completed on 6/11/24; individual rights, completed on 2/6/24; individual-specific reviews on the safe and appropriate use of behavior support plans, completed on 4/12/24; and individual-specific reviews on the implementation of individual support plans, completed on 2/6/24. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | On 11/20/2025, Program Director updated training template to include the topic of training, trainer's name, location of training, date and time. |
11/20/2025
| Implemented |
| 6400.182(c) | Individual #1's Service Plan, last updated 10/16/25, contained the following discrepancies between their current assessment, completed on 3/28/25, in the following health and safety skill domains: regarding home supervision, Individual #1's Service Plan, last updated 10/16/25, explained that Individual #1 requires 24-hour supervision, that "[Individual #1] is able to maneuver through the home with staff checking on [them] frequently, [that] [Individual #1] is able to be alone in the home for a short period of time as long as all of [their] needs are met, while staff are scrapping the sidewalk, getting the mail, or prepping the van; [and] [that] [Individual #1] needs monitored because [they] will eat inedible objects." However, Individual #1's assessment, completed on 3/28/25, indicated only that Individual #1 can be left unsupervised for short intervals of time with staff nearby who must check on them intermittently. (Staff may clean outside sidewalk and get the van ready); and regarding ability to complete oral hygiene, Individual #1's Service Plan, last updated 10/16/25, left this area unaddressed, stating only that "[Individual #1] likes to have a neat and clean appearance, and personal hygiene is important to [them]." In contrast, Individual #1's assessment, completed on 3/28/25, indicated a score of "0," meaning that Individual #1 cannot perform the skill of completing oral hygiene. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | On 12/3/2025, Program Specialist emailed Individual #1's Supports Coordinator to request the following information be changed in his ISP to reflect his needs:
- Individual #1 can be unsupervised for up to 5 minutes within the home while staff are scraping the sidewalk, getting the mail, or prepping van during winter. Staff will check on him every 5 minutes while they are completing a task within close proximity.
- Individual #1 has never been known to eat an inedible object and needs removed from the ISP.
- Supervision care needs: The home is staffed 24/7, however Individual #1 can spend alone time in his room throughout the day.
- Individual #1 is non-verbal and has never expressed the desire to maintain a neat and clean appearance. This is being moved to the like and admire section of the ISP. |
12/03/2025
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(11) | The physical examination completed on 2/10/16 for Individual #1 did not include an assessment of the individual's health maintenance needs. This section was left blank. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | A training was held on 1-17-2017, including the Program Specialists, Program Assistant and the Program Director, to review the physical form and the requirements for completing all sections including the health maintenance section. When an Individual is taken for a physical, the physician will be instructed to complete all sections of the physical form. If there are no recommendations to be made for a section it cannot be skipped over. Any section that does not require attention at the time of the visit must be marked with an NA. The Program Assistant will be responsible for a second check of all physicals to ensure all sections are completed. No physical form will be excepted unless all sections are filled out. [By 2/10/17, Individual #1 will have a physical examination completed to include an assessment of the individual's health maintenance needs. Immediately, all staff persons responsible for assisting individual in physical examinations shall be trained as to what is included in physical examinations as per 6400.141(c)(1)-(15) and the that not any required areas shall be left blank. Documentation of training shall be kept. Within 1 week of competition, the program assistant shall review all individuals' physical examination and immediately obtain missing information from the completing physician. At least quarterly for 1 year, the program director shall review a 25% sample of individuals' physical examinations to ensure all required area of physical examinations are addressed. Documentation of reviews shall be kept. (AS 1/26/17) |
01/17/2017
| Implemented |
| 6400.141(c)(15) | The physical examination completed on 2/10/16 for Individual #1 did not special instructions for the individual's diet. | The physical examination shall include:Special instructions for the individual's diet. | A training was held on 1-17-17, including the Program Specialists, Program Assistant and the Program Director to review the physical form and the requirements for completing all sections. There were a few physical forms where the instructions for special diet had been deleted. These forms were replaced with the corrected form and all sections must be completed for the physical to be accepted. The Program Assistant will be responsible for a second check of all physicals to ensure all sections are completed. No physical form will be accepted unless all sections are filled out completely.[By 2/10/17, Individual #1 will have a physical examination completed to include special instructions for the individual's diet. Immediately, all staff persons responsible for assisting individual in physical examinations shall be trained as to what is included in physical examinations as per 6400.141(c)(1)-(15) and the that not any required areas shall be left blank. Documentation of training shall be kept. Within 1 week of competition, the program assistant shall review all individuals' physical examination and immediately obtain missing information from the completing physician. At least quarterly for 1 year, the program director shall review a 25% sample of individuals' physical examinations to ensure all required area of physical examinations are addressed. Documentation of reviews shall be kept. (AS 1/26/17) |
01/17/2017
| Implemented |
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