| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.18(a)(4) | Individual #2 was subjected to the abuse of Individual #1 by proximity. Following the incident, staff members involved in the abuse continued to have access to Individual #1, Individual #2, and other individuals in Kels LLC's care. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Abuse, including abuse to a individual by another client.
| Going forward all incidents will be reported within 24hrs by the CEO, and any staff members who are identified as having taken part in incident will be immediately taken off the schedule and will not have any access to the individual. |
09/03/2025
| Not Accepted |
| 6400.18(f) | Individual #2 was subjected to the abuse of Individual #1 by proximity. Following the incident, staff members involved in the abuse continued to have access to Individual #1, Individual #2, and other individuals in Kels LLC's care. The provider failed to take immediate action to restrict the abusive staff or otherwise implement protective measures, placing all individuals at ongoing risk of further harm. | The home shall take immediate action to protect the health, safety and well-being of the individual following the initial knowledge or notice of an incident, alleged incident or suspected incident. | All implicated staff were removed from operational authority and individual contact effective 09/02/2025. A Protective Staffing Plan was activated to ensure uninterrupted care by qualified staff. Individuals #2 received medical and behavioral health follow-up and safety checks. |
09/02/2025
| Not Accepted |
| 6400.18(g) | Kels LLC failed to initiate an investigation within 24 hours of the abuse depicted above. | The home shall initiate an investigation of an incident, alleged incident or suspected incident within 24 hours of discovery by a staff person. | Incident entered into EIM, Investigation plan developed, investigator assigned, and entries documented in EIM. |
09/02/2025
| Not Accepted |
| 6400.32(c) | Individual #2 was subjected to the abuse of Individual #1 by proximity. Exposure to physical abuse, even when not directed at Individual #2, places the person at risk of emotional or psychological harm. The individual may experience fear, anxiety, and distress simply by being present during incidents of abuse. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | All staff was retrained on individuals rights. |
09/02/2025
| Not Accepted |
| 6400.32(d) | Individual #2 was subjected to the abuse of Individual #1 by proximity. As a result of the exposure to physical abuse even when not directed at Individual #2, places the person at risk of emotional or psychological harm. The individual may experience fear, anxiety, and distress simply by being present during incidents of abuse. | An individual shall be treated with dignity and respect. | All Staff will be retrained on the rights of the individual to ensure that each individual is treated with respect and dignity. |
09/03/2025
| Not Accepted |