| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | At the time of the inspection, the majority of the white kitchen cabinets had and unidentifiable brown substance around the silver knobs/handles. Some of the silver knobs/handles to the cabinets had a sticky substance on them when the Licensing Representative touched them to open them up. | Clean and sanitary conditions shall be maintained in the home. | Provider staff immediately cleaned the cabinet and correct the issue at the time of the inspection. |
07/10/2025
| Implemented |
| 6400.80(b) | At the time of the inspection, the outside patio/yard had weeds growing up between the concrete pavers, and some of the weeds were up to approximately the Licensing Representatives (LR) ankle. There was also patches/sections of grass that were also approximately up to the LR ankles. There were also areas of the yard/patio with brown/dead grass, leaves, and other dead debris. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The outside patio /yard weeds trimmed on 7/12/25 . |
07/10/2025
| Implemented |
| 6400.110(f) | The individual residing in the home has a hearing impairment and requires a bed shaker to alert the individual in case of a fire. At the time of the inspection, the bed shaker did not activate when the fire alarm was sounded. | If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. | Agency has contacted a fire agency to install a strobe in the home on july 24, 2025. Installation will take place on 8.10.25 |
07/24/2025
| Implemented |
| 6400.112(e) | Individual #1's date of admission into the home was 7/31/24, and that was when the first fire drill was conducted in the home. A sleeping drill did not occur in the home until 4/8/25. This exceeds the requirement. | A fire drill shall be held during sleeping hours at least every 6 months. | A calendar was formulated on 7.12.24 by manager to ensure fire drill compliance, |
07/12/2025
| Implemented |
| 6400.181(e)(2) | Individual #1's assessment dated 9/30/24 did not include Individual #1's dislikes. | The assessment must include the following information: The likes, dislikes and interest of the individual. | Program specialist reviewed all assessment on 7.12.24 to ensure pertinent information are captured on all forms |
07/12/2025
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's assessment dated 9/30/24 did not assess Individual #1's current level of financial management skill/ability. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| Program specialist reviewed all assessment on 7.12.24 to ensure pertinent information are captured on all forms |
07/12/2025
| Implemented |
| 6400.211(b)(1) | Individual #1's emergency contact information did not include the name and the relationship of a designated person to be contacted in case of an emergency. The emergency contact just had an address and phone number listed on the document. | Emergency information for each individual shall include the following: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency.
| Program specialist reviewed all assessment on 7.12.24 to ensure pertinent information are captured on all forms |
07/12/2025
| Implemented |
| 6400.211(b)(3) | Individual #1's record did not include the name, address, and telephone number of the person able to give consent for emergency medical treatment. | Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.
| Program specialist reviewed all assessment on 7.12.24 to ensure pertinent information are captured on all forms |
07/12/2025
| Implemented |
| 6400.34(a) | Individual #1 was informed of his rights on 7/31/2024. The rights haven't been updated to reflect the current Chapter 6400 regulations. The missing rights include: An individual may not be discriminated against because of race, color, creed, disability, religious affiliation, ancestry, gender, gender identity, sexual orientation, national origin, or age, individual may not be exploited or abandoned, shall be treated with dignity and respect, make choices and accept risks, refuse to participate in activities and services, control his own schedule and activities, privacy of person and possessions, receive scheduled and unscheduled visitors at any time, access to other forms of communications, unopened and unread by others, including the right to share contact information with whom the individual chooses, choose persons with whom to share a bedroom, furnish and decorate the individual's bedroom and the common areas of the home in accordance with § 6400.33, lock the individual's bedroom door, Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to unlock and lock the door, access to an individual's bedroom shall be provided only in a life-safety emergency or with the express permission of the individual for each incidence of access, assistive technology shall be provided as needed to allow the individual to open and lock the door without assistance, the locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency, direct service workers who provide services shall have the key or entry device to lock and unlock the door, right to have a key, access card, keypad code, or other entry mechanism to lock and unlock an entrance door of the home, access food at any time, make health care decisions, and an individual's right may only be modified in accordance with § 6400.185 (relating to content of individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others. | 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. | Agency has updated right form to ensure compliance with ODP on 7.12.25 |
07/12/2025
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medications to treat the symptoms of a diagnosed psychiatric illness and had a medication review on 10/22/2024, then not again until 4/21/2025 which exceeds the 3-month timeframe required by this regulation. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | A calendar was developed by program specialist on 7/20/25 to ensure Indvidual see a psychiatrist doctor every three as required by ODP. Program specialists collaborated with Psychiatrist to ensure calendar update and agency comply with ODP quarterly medication review. |
07/20/2025
| Implemented |
| 6400.194(d) | A record of the human rights team meeting shall be kept. The agency conducted human rights team (HRST) meetings for Individual #1 on 10/20/24, 1/18/25, and 5/19/25 for Individual #1 "restriction phone access". The HRST meeting documentation did not meet all the requirements and meeting components outlined in the ODP Bulletin 00-21-01, Guidance for Human Rights Teams and Human Rights Committees. The 10/20/24, 1/18/25, and 5/19/25 meeting documentation only listed the names of the members that were present at the meeting, Incidents that occurred, however the 1/18/25 meeting document did not even completely list the 2 incidents that were allegedly reported, and that all member voted to continue the restrictions. Some of the requirements that were missing from the HRST documentation were: A presentation by the person responsible for monitoring and documenting progress with the behavior support component of the Individual Plan, Review of information contained in the behavior support component of the Individual Plan, an assessment of the behavior including the suspected function of the behavior, The desired outcome of the suggested restrictive procedure, Target dates for achieving the outcome, etc. | A record of the human rights team meetings shall be kept. | A new behavior support plan has been created on 7.15,25 by agency Behavior Support person to ensure compliance, The Plan high light restrictions and a human right committee will meet every 6 months to ensure restrictions are reviewed, |
07/15/2025
| Implemented |
| 6400.195(a) | At the time of the inspection the only telephone in the home was locked in the office. Individual #1 date of admission is 7/31/24 and Individual #1 had n IDD Restrictive Behavior Plan Restive Procedure Plan (RPP) in their record from another provider the individual resided with previously with the date of plan 03-Jun-2024 and latest revision 09-Jul-2024. Another Behavior Support Plan from their agency dated 6/29/25 that has a RPP in it was also in Individual #1's record. The provider is implementing a restrictive procedure without a behavior support plan reviewed by a human rights team that addresses the need for the restrictive procedure. | For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures. | A new behavior support plan has been created on 7.15,25 by agency Behavior Support person to ensure compliance, The Plan high light restrictions and a human right committee will meet every 6 months to ensure restrictions are reviewed, |
07/15/2025
| Implemented |
| 6400.195(c)(8) | Individual #1's date of admission is 7/31/24 and they had an IDD Restrictive Behavior Plan (RPP) from their prior agency, and it was contracted with another/separate agency with the date of the plan of 03-Jun-2024 and latest revision 09-Jul-2024. The Behavior Specialist at the contracted agency and prior agency were responsible for monitoring the plan and collecting data. However, since Individual #1 moved to Community Initiative Group the staff identified in the RPP latest revision 09-Jul-2024 from the other agencies have not seen or been monitoring and documenting the behavior support component of the individual plan. | The behavior support component of the individual plan shall include: The name of the staff person responsible for monitoring and documenting progress with the behavior support component of the individual plan. | A new behavior support plan has been created on 7.15,25 by agency Behavior Support person to ensure compliance, The Plan high light restrictions and a human right committee will meet every 6 months to ensure restrictions are reviewed, |
07/15/2025
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not include identifying marks as this was left blank on the form. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number, Height · Weight · Color of hair · Color of eyes · Identifying marks | Program specialist has updated assessment form to ensure compliance. |
07/21/2025
| Implemented |