| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | Individual #1's service plan, last updated 7/1/2025, reads, "[Individual #1] requires assistance with managing [their] money and budgeting accordingly." Staff interviews revealed that Individual #1 understands that money is needed to purchase things but does not know the correct amount needed or how much change should be received. Staff assist Individual #1 with purchases. The provider agency is not maintaining an up-to-date financial ledger of funds received by or deposited with the home. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | The agency has put in place a financial ledger/record document to have at every location. They agency has a separate inventory document that is used and updated when new items are bought by the individual, friend or family members. |
01/21/2026
| Implemented |
| 6400.22(d)(2) | Individual #1's service plan, last updated 7/1/2025, reads, "[Individual #1] requires assistance with managing [their] money and budgeting accordingly." Staff interviews revealed that Individual #1 understands that money is needed to purchase things but does not know the correct amount needed or how much change should be received. Staff assist Individual #1 with purchases. The provider agency is not maintaining an up-to-date financial ledger of disbursements made to or for Individual #1. | (2) Disbursements made to or for the individual.
| The agency has put in place a financial ledger/record document to have at every location. They agency has a separate inventory document that is used and updated when new items are bought by the individual, friend or family members. |
01/21/2026
| Implemented |
| 6400.77(b) | On 12/22/2025 at 2:13PM, the first aid kid did not contain a scissors and a thermometer. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | Immediately upon notification by the licensor, the missing tweezers and scissors were replaced in the first aid kit on the same day of the inspection. The first aid kit was reviewed to ensure all required items were present and fully stocked in accordance with the regulations. |
01/21/2026
| Implemented |
| 6400.141(c)(4) | Individual #1, date of admission 4/15/2024, had a hearing screening most recently on 8/24/2024. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | The agency has update the Individuals Physical form to include that these are checked at the time of the annual physical. |
03/06/2026
| Implemented |
| 6400.141(c)(11) | Individual #1's physical examination, completed 7/7/2025, did not include an assessment of the individual's health maintenance needs. | 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. | The agency has developed a new Annual Physical Form and has implemented it immediately for all individuals. |
03/06/2026
| Implemented |
| 6400.142(f) | Individual #1, date of admission 4/15/2024, did not have a dental hygiene plan. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | The Program Specialist completed a written dental hygiene plan for the individual outlining the supports needed to maintain proper dental hygiene, including staff assistance and monitoring requirements. The dental hygiene plan was added to the individual's record and staff were notified of the plan and expectations for implementation. |
03/06/2026
| Implemented |
| 6400.181(e)(4) | Individual #1's assessment, completed 5/25/2025, states that Individual #1 can be left alone in the home. Staff interviews revealed that this information is incorrect and Individual #1 cannot be left unsupervised in the home. | The assessment must include the following information: The individual's need for supervision.
| this area of the assessment was reviewed and updated. |
03/06/2026
| Implemented |
| 6400.181(e)(12) | Individual #1's assessment, completed 5/25/2025, 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. | this area of the assessment was reviewed and updated. |
03/06/2026
| Implemented |
| 6400.182(c) | Individual #1's assessment, completed 5/25/2025, states that Individual #1 is able to evacuate independently in the event of a fire. Individual #1's service plan, last updated 7/1/2025, reads, "[Individual #1] would be physically able to exit a building in case of a fire but would probably become confused so [they] would require some guidance." Recent fire drills, conducted on 9/7/2025 and 11/8/2025 stated that Individual #1 required verbal prompts from staff to evacuate the home. Individual #1's assessment, completed 5/25/2025, states that Individual #1 is able to complete hygiene tasks independently. Individual #1's service plan, last updated 7/1/2025, reads, "[Individual #1] needs prompting with washing [themself] during bathing and other hygiene tasks. [Individual #1] needs some assistance to make sure that [Individual #1] is brushing [their] teeth thoroughly." Staff interviews revealed that Individual #1 does often require verbal prompts to complete hygiene tasks. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The individuals assessment has been updated and ISPs have been reviewed. The SCs will be notified of the changes that need to made in the ISPs. |
03/06/2026
| Implemented |