| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | No self-assessment was completed for this location. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| We Care For All acknowledges that a self-assessment was not completed for this location within the required timeframe. A self-assessment has now been completed to bring the location into compliance. |
07/28/2025
| Implemented |
| 6400.43(b)(1) | The 7/1/25 signed room & board contract for individual #1 does not have a designated amount written on it. Selection #1 is circled on the form, but the amount is left blank. The agency had the individual sign a contract where any amount could then be written in later. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | We completed the SSI Room and Board contract for Individual #1 based on the confirmed rate provided by the representative payee. However, we acknowledge that the 2/13/25 signed contract did not include a designated amount. |
07/03/2025
| Implemented |
| 6400.67(b) | The light switch at the top of the basement staircase does not have a switch plate on it presenting a potential hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | We Care For All acknowledges that the light switch at the top of the basement staircase did not have a switch plate, presenting a potential hazard. A new switch plate has since been installed to correct the issue. |
07/28/2025
| Implemented |
| 6400.101 | The lock on individual #1's bedroom door was installed backwards in such a way that it could only be locked from the outside.
*This was fixed the day of inspection* | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| We Care For All acknowledges that the lock on Individual #1's bedroom door was installed backwards, allowing it to be locked from the outside. This issue was corrected on the day of inspection, and the lock was reinstalled properly so that it can only be locked from the inside. |
07/03/2025
| Implemented |
| 6400.110(e) | The smoke detectors in the home were operational, however they were not interconnected with each other and the home has 3 stories. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | We Care For All had an electrician inspect the wired smoke detectors and determined that the basement smoke detector was inoperable, which caused the other detectors to not be interconnected. The electrician installed and wired a new smoke detector in the basement, and all detectors are now interconnected and operational throughout the home. |
07/28/2025
| Implemented |
| 6400.113(a) | Individual #1 was not instructed in fire safety upon initial admission on 7/1/25. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | We Care For All acknowledges that Individual #1 was not instructed in fire safety upon initial admission on 7/1/25. The individual has since been instructed in general fire safety, evacuation procedures, responsibilities during fire drills, and the designated meeting place in the event of a fire. |
07/28/2025
| Implemented |
| 6400.34(a) | The Individual rights form for individual #1 signed upon admission on 7/1/25 does not include the right to lock the bedroom door. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | We Care For All acknowledges that the individual rights form signed on 7/1/25 for Individual #2 did not include the right to lock their bedroom door. To correct this, Individual #1 has since signed a new individual rights form that includes this right. |
07/28/2025
| Implemented |
| 6400.169(b)(2) | Individual #1 is prescribed Zepbound 7.5mg Inj. however the staff in the home do not have the department approved diabetes patient training. | A staff person may administer insulin injections following successful completion of both: A Department-approved diabetes patient education program within the past 12 months. | We Care For All acknowledges that Individual #1 is prescribed Zepbound 7.5 mg injections; however, staff in the home have not yet completed the Department-approved diabetes patient education program required to administer injectable medications. Staff are scheduled to complete the required diabetes patient education training. Until training is completed, only properly trained personnel or the prescribing healthcare professional will administer Zepbound to Individual #1. |
07/28/2025
| Implemented |