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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(a) | At 12:34 PM on 8/13/25, the three operable kitchen windows facing the rear of the home did not have screens. [Repeated Violation-8/29/24] | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Provider has asked the building owner to permanently close the windows so that they cannot be opened. The windows are very high and small, and could not be used as an emergency exit. They are never used for ventilation as the Individual does not tolerate windows being opened. Screens in the windows would limit the view and light, and would make it more difficult for the window cleaner to clean the windows (from the outside), so the best option is to install blocks to prevent the windows from being opened. |
08/18/2025
| Implemented |
| 6400.104 | The agency provided the home's Local Fire Department Notification Letter, dated 7/1/25. The letter indicated that Individual #1 requires evacuation assistance in the event of an actual fire but did not address the current following information: the home's capacity; a description or diagram of the home's layout; or a general description of Individual #1's mobility needs. | 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.
| The notification letter to the local fire department has been revised and the new one will be sent to the fire department after approval of this POC. To address occupancy, the word "an" individual has been changed to "one". More detail has been added to possible assistance that may be needed by the individual. "If his path to exit is blocked, the individual may also need physical assistance navigating the obstacles and exiting the building." A floor plan has been included at the bottom of the letter to give more detail to the location previously written as, "His bedroom is located in the front left corner of the building." |
08/18/2025
| Implemented |
| 6400.141(c)(11) | Individual #1's current physical examination, completed on 1/8/25, did not include an assessment of their health maintenance needs, as there was no corresponding field. | 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. | This was a clerical error. When I submitted the form to the physician for his completion during the examination, the Health Maintenance field was somehow deleted. It is on my electronic blank version. I have created a pdf version so that it cannot be accidentally altered in the future. |
08/18/2025
| Implemented |
| 6400.181(e)(11) | Individual # 1's current assessment, completed on 4/15/25, did not include an applicable psychological evaluation, as the corresponding field read, "[Their] last psychiatric evaluation was on 2/5/25." However, Individual # 1's psychological evaluation was not attached or included in their content of records. | The assessment must include the following information: Psychological evaluations, if applicable. | The wording for the field referenced has been changed to avoid confusion. It now reads, "His last psychiatric medication evaluation was on 2/5/25." His last psychological evaluation from Western Psychiatric Hospital, which is referenced in the history as completed in 1997, has been obtained and in the future will be included with his assessment in the future. |
08/18/2025
| Implemented |
| 6400.46(d) | Chief Executive Officer/ Program Specialist #1, who also provides direct care, completed two-year certification trainings in first aid, Heimlich techniques, and cardio-pulmonary resuscitation through the American Red Cross on 3/2/23, and then again on 4/7/25. Direct Service Provider #2 completed two-year certification trainings in first aid, Heimlich techniques, and cardio-pulmonary resuscitation through the American Red Cross on 9/29/22, and then again on 10/5/24. | 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. | The CPR trainings have already been completed, but in the future the provider will ensure that trainings will be completed in a timely manner to avoid violations. |
08/18/2025
| Implemented |
| 6400.50(a) | Direct Service Provider #2 and Direct Service Provider #3 completed annual training in recognizing and reporting incidents on 12/8/24, for the 2024 calendar year. However, these completed trainings did not include the training source. Direct Service Provider #4, with a date-of-hire on 11/22/24, completed orientation training in recognizing and reporting incidents on 1/8/25. However, this completed training did not include the training source. | 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. | For the new employee hired on 12/22/2024, the training source and length of time that the Incident Management training took has been documented on her Initial Training Record. In addition the Initial and Annual Training Curriculums used by the provider have been updated to include the training source, and length of training as well as a sign in sheet to certify that employees completed the training. |
08/18/2025
| Implemented |
| 6400.182(c) | Individual #1's Service Plan, last updated 7/28/25, contained the following discrepancies between their current assessment, completed on 4/15/25, in the following health and safety skill domains: regarding poisonous materials, Individual #1's Service Plan, lasted updated 7/28/25, stated, "[Individual #1] is safe with poisonous liquids, etc. [They] would understand not to ingest non-food or poisonous items. Staff assist [Individual #1] for [their] health and safety." However, Individual #1's assessment, completed on 4/15/25, informed that "[Individual #1] understands some poisonous materials, such as cleaning supplies, and would avoid them if they were in [Individual #1's] presence."; regarding non-insulated heat sources exceeding 120 degrees Fahrenheit, Individual #1's Service Plan, last updated 7/28/25, explained that "Staff continue to supervise [Individual #1] near heat sources to ensure [their] health and safety." In contrast, Individual #1's assessment, completed on 4/15/25, indicated that Individual #1 can sense and quickly move from dangerous heat sources with independence; regarding supervision in the home, Individual #1's Service Plan, last updated 7/28/25, informed that Individual #1 requires 24-hour supervision, must always be within hearing distance of staff, but requires to be within eyesight supervision during times of heightened anxiety, as Individual #1 does not tolerate changes in their routine. In addition, staff provide assistance to complete activities of daily living. However, Individual #1 assessment completed on 4/15/25, stated that Individual #1 requires a 1:1 staffing ratio and "can be left unsupervised in the home as long as someone is in the home with [them] within hearing range, checking on [Individual #1] every 15 minutes."; and regarding supervision in the community, Individual #1's Service Plan, last updated 7/28/25, explained that Individual #1 requires 24-hour supervision at all times to ensure their safety and wellbeing and that Individual #1 must be within arm's length when negotiating traffic. In contrast, Individual #1's assessment, completed on 4/15/25, left community supervision unaddressed, as there was no reference to or language specifically addressing this area. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Regarding poisonous materials, the statement from the assessment was incorrectly quoted. The assessment said, ¿Mark understands that some materials, such as cleaning supplies, are poisonous and would avoid them if they were in his presence.¿ To avoid future misinterpretations and to provide further guidance, the assessment has been revised and now says, ¿Mark understands that some substances are poisonous and would know to avoid them if they were in his presence. Mark knows how to safely use household cleaning products, in such a way to avoid inhalation, ingestion, or irritation.¿
Regarding heat sources, the ISP and Assessment have been revised so that they are both in agreement with their statements, and further information has been added to each to avoid misunderstanding. I will email the revised assessment to verify that changes have been made and for comparison to the ISP.
Regarding supervision, additional information was added for further clarification. Supervision in the community was addressed. The revised assessment will be separately emailed. |
08/18/2025
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(a) | At 12:14PM, there was not a screen in the window behind the bed in Individual #1's bedroom. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Window screens were promptly ordered and installed in the Individual's bedroom windows. |
09/04/2024
| Implemented |
| 6400.72(b) | At 12:16PM, there was an eight-inch by one-inch tear in the screen in the window on the right side of Individual #1's bedroom. | Screens, windows and doors shall be in good repair. | New screens were promptly ordered and installed in the Individual's bedroom windows, replacing the screen that had a tear. |
09/04/2024
| Implemented |
| 6400.80(b) | At 12:36PM, numerous items, including but not limited to, two large ladders, a smaller ladder, buckets of paint, two wooden sawhorses, a hose, pipes, a paint tray, pieces of wood, bins, and other miscellaneous items, were in front of the attached garage in the back of the home. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The outside of the building was cleaned up so that no unsafe conditions exist. All items in front of the garage area behind the home were removed so that it is free and clear. |
09/02/2024
| Implemented |
| 6400.106 | The home is equipped with a boiler heating system that has not been cleaned or inspected. | 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.
| A HVAC professional performed an inspection and cleaning of the residential boiler heating system. Details of the service completed are listed on the service invoice. |
09/06/2024
| Implemented |
| 6400.107 | At 12:29PM, a portable space heater was on a shelf in the attached garage of the home. | Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including staff rooms.
| The space heater has been removed and disposed of properly. It is no longer in the garage. Agency supervisor talked with the building owner who uses the garage for storage, and explained that space heaters are not allowed to be stored on the premises. He has agreed to not store them there in the future. |
09/02/2024
| Implemented |
| 6400.112(f) | The front door was used as the exit route for all monthly fire drills held between August 2023 and August 2024. | Alternate exit routes shall be used during fire drills. | The Program Specialist has developed a plan to work on the Individual being willing to use the back door as an exit during a fire drill. The plan has been shared with the Individual and his team. It has been implemented, and we will be working towards the goal for a successful fire drill by the end of the 2024. |
09/01/2024
| Implemented |
| 6400.181(f) | Program Specialist #1 provided Individual #1's assessment, completed 4/15/2024, to the plan team members on 4/22/2024 for the annual Individual Plan meeting on 5/7/2024. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Going forward, the Program Specialist will provide the assessment to the team 30+ days before the ISP meeting. |
08/30/2024
| Implemented |
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