| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.104 | The home's undated Fire Department Notification Letter did not provide the exact bedroom location of Individual #1, who requires assistance to evacuate in the event of a fire, as the letter lacked a description and/or diagram of the home's general layout for reference to provide specificity to the vague bedroom location given. This Fire Department Notification Letter read as follows: "[Individual #1] is ambulatory but will require assistance to exit the home in case of an emergency. [Individual #1's] bedroom is located at the end of the hall." | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Provider will resend fire department notification letters with an attached floor plan documenting exact location of bedroom for the individuals. |
03/25/2026
| Implemented |
| 6400.106 | The home's furnace was inspected on 9/18/24, and then again on 11/10/25. In addition, the furnace inspection invoices provided for 9/18/24 and 11/10/25 did not include documentation that the home's furnace was also cleaned. | 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.
| DTE's CEO Spoke with Cochran's Heating and Air (provider of furnace inspection and cleaning) to investigate why this occurred. We were late in the scheduling for this past year due to their office changing personnel and an oversight with our renewal being due. We are currently renewed for another 3 year contract. In addition we requested that Cochran's update their printouts to reflect what cleaning was done. They agreed to do so and emailed us an update of the previous inspection paperwork for our records. |
03/23/2026
| Implemented |
| 6400.141(c)(12) | Individual #1's current physical examination, completed on 6/12/25, did not address physical limitations of the individual, as the corresponding field was left blank. | The physical examination shall include: Physical limitations of the individual. | The violation occurred because staff did not make sure all areas of the physical were filled in with information about the individuals physical limitations instead of left blank. Staff will take the physical to go get completed by a physician filling in the physical limitation information as well as any other areas that may need completed by 04/04/2026. |
03/27/2026
| Implemented |
| 6400.141(c)(14) | Individual #1's current physical examination, completed on 6/12/25, did not address medical information pertinent to diagnosis and treatment in case of an emergency, as the corresponding field was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The violation occurred because staff did not make sure all areas of the physical were filled in with information pertinent to diagnosis and treatment in case of emergency. Staff will take the physical to go get filled in by a physician filling in the individual's pertinent to diagnosis and treatment in case of emergency as well as any other areas that may need completed. |
04/04/2026
| Implemented |
| 6400.181(e)(11) | Neither Individual #1's current assessment, completed on 5/31/25, nor their content of records included an applicable psychology evaluation or a documentation request to procure one. | The assessment must include the following information: Psychological evaluations, if applicable. | The program specialist failed to include the most recent Psychological evaluation on the assessment. The program specialist contacted the individuals Psychologist and they sent the most recent psychiatric evaluation available. It has been added to the Assessment. |
03/28/2026
| Implemented |
| 6400.181(e)(12) | Individual #1's current assessment, completed on 5/31/25, did not include recommendations for targeted skill growth goals with specific areas of programming, training, and services indicated for implementation, as the corresponding field contained a combination of diagnoses and broad concepts (i.e.: MRSA, Autism Spectrum; Positive Approaches, Rheumatoid Arthritis, etc.) with a statement that read: "Staff have given positive feedback numerous times about [Individual #1's] progress, activity level, and happiness with [their] current situation." | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The Program Specialist already included a recommendation of "communication" for the individual to improve. He has now elaborated to a more specific skill set and has added a training aimed specifically at Kyle's shyness when communicating. |
03/28/2026
| Implemented |
| 6400.50(a) | Individual #1 completed annual fire safety training on 4/29/24, and then again on 4/29/25. However, documentation for both of these fire safety training records did not include the trainer who facilitated these sessions. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | The current fire safety training form has witness instead of trainer signature listed. The form will be updated to state trainer signature and the fire safety trainings will be redone utilizing the corrected form. |
03/25/2026
| Implemented |