| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The basement had a mildew like smell. The finishing of the walls and floor was rough appeared to be covered with an unknown substance (growth of some sort) that need to be addressed to ensure that the area is not unsafe for the environment. | Clean and sanitary conditions shall be maintained in the home. | On 5/19/25 Program Specialist contacted maintenance company who came out and cleaned the basement. |
05/19/2025
| Implemented |
| 6400.77(b) | The 1st aid kit was missing tweezers. | 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. | On 5/19/25 Program Specialist purchased tweezers. |
05/19/2025
| Implemented |
| 6400.106 | There was no record that the furnace was inspected at the time of the review. | 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.
| On 5/19/25 Program Specialist contacted company to come out and inspect furnace which was inspected on 5/20/25. |
05/20/2024
| Implemented |
| 6400.141(c)(10) | 141c(10) The annual physical did not have the communicable disease precautions section completed | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | As of May 23, 2025, the individual's physician provided a letter confirming that the individual is free of communicable disease which has been placed in the individual's file. |
05/23/2025
| Implemented |
| 6400.141(c)(14) | 141(c)(14) The annual physical did not have the Info pertinent to diagnosis in case of emergency completed. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | As of May 23, 2025, the individual's physician provided a letter confirming that the individual is free of communicable disease which has been placed in the individual's file. |
05/23/2025
| Implemented |
| 6400.151(c)(2) | There was no record on file and the physical exam did not include TB test or results for staff number one. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | Staff #1 is no longer employed with the agency and is unavailable to provide updated documentation. Therefore, the missing information from the 2023 physical cannot be obtained. |
05/21/2025
| Implemented |
| 6400.151(c)(3) | Staff number one's physical exam form does not say if the staff is free from communicable diseases. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | Staff #1 is no longer employed with the agency and is unavailable to provide updated documentation. Therefore, the missing information from the 2023 physical cannot be obtained. |
05/21/2025
| Implemented |
| 6400.151(c)(4) | Staff number one physical exam dated 12/29/23 did not indicate information if there were medical problems which might interfere with the health of the individuals | The physical examination shall include: Information of medical problems which might interfere with the health of the individuals. | Staff #1 is no longer employed with the agency and is unavailable to provide updated documentation. Therefore, the missing information from the 2023 physical cannot be obtained. |
05/21/2025
| Implemented |
| 6400.151(c)(4) | Staff number two physical examination dated 7/11/22 was missing Information of medical problems which might interfere with the health of the individuals. | The physical examination shall include: Information of medical problems which might interfere with the health of the individuals. | Effective 5-21-25, all staff physical exam forms will be reviewed by the Program Specialist upon submission to ensure that the required section addressing medical problems that may interfere with individual health and safety is completed. Any incomplete forms will be returned for correction prior to being accepted into the staff file. Staff will be required to return to their healthcare provider to obtain complete documentation before clearance for work is granted. |
05/21/2025
| Implemented |
| 6400.181(a) | There was no initial or annual updated assessment completed in the records at the time of the review. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | As of May 21, 2025, an updated assessment has been completed and placed in the individual's file. The assessment includes current information regarding the individual's health status, support needs, risks, and preferences, and was reviewed by the care team. |
05/21/2025
| Implemented |
| 6400.217 | There was no written consent for the individual on file at the time of the review. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| Provider agency created consent form. Program Specialist explained form to individual and it has been signed and added to individual's file. on 5/19/25. |
05/19/2025
| Implemented |
| 6400.183(c) | The list of persons who participated in the individual plan documentation was not in the records for the current plan meeting | The list of persons who participated in the individual plan meeting shall be kept. | Immediately upon notification of the citation, on 5/19/25 Program Specialist contacted individual's support coordinator and obtained a copy of the list of persons who participated in the individual plan meeting. |
05/19/2025
| Implemented |