| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | The bathroom closet and beneath the kitchen sink contained unsecured poisonous cleaning products - Individual 1's ISP states poisons must be locked. | Poisonous materials shall be kept locked or made inaccessible to individuals. | All poisonous and hazardous cleaning products were immediately removed from unsecured locations and placed in locked storage areas that are inaccessible to Individual 1.
To prevent reoccurrence, all staff were re-educated on the Individual Support Plan (ISP) requirements regarding hazardous materials and the agency policy that poisonous substances must be locked or inaccessible at all times. Staff will complete environmental safety checks at the beginning of each shift to ensure compliance. |
01/13/2026
| Implemented |
| 6400.64(e) | The kitchen trashcan was more than 18" tall but did not have a lid. | Trash receptacles over 18 inches high shall have lids. | The uncovered trash receptacle was immediately removed and replaced with a trash can of appropriate size that includes a secure, fitted lid.
Staff were re-educated on environmental safety and household standards, including the requirement that all trash cans must have lids. Environmental checks will include verification of proper trash cans in all common areas. |
01/13/2026
| Implemented |
| 6400.65 | Mechanical ventilation was not present in the rear bedroom, and the windows were inoperable due to being covered in plywood. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| The plywood covering the bedroom windows was removed, and the windows were restored to full operability to allow proper ventilation.
Maintenance staff and program leadership were re-educated on environmental safety and ventilation requirements. Any temporary window coverings must be approved and cannot impede ventilation. |
01/07/2026
| Implemented |
| 6400.67(a) | The front storm door is missing the upper glass panel. The lower-level storm door has a broken lower panel. The siding at the back of the house near the roof is falling off. The rear downspout is missing a section. The handrail on and above the stairs is missing numerous banisters. Many basement floor tiles are broken and the pieces are scattered in the area. The stove is missing the range grates, and the front glass panel of the oven is shattered. The majority of windows in the home were boarded up, regardless of the condition of the windows themselves. The front entrance room of the house has plastic sheeting stapled to cover the side walls/windows. | Floors, walls, ceilings and other surfaces shall be in good repair. | Immediate actions were taken to secure the environment and remove any hazards. A contractor has been secured to address all noted repairs, and corrective work is currently in progress. Repairs include replacement of damaged doors, siding, downspout, handrails/banisters, windows, flooring, and kitchen appliances. Temporary coverings that interfered with safety, lighting, or ventilation are being removed as repairs are completed.
The agency will maintain a preventative maintenance plan to ensure the home remains in safe and habitable condition. |
01/19/2026
| Implemented |
| 6400.67(b) | The handrail in the home is structurally unsound due to the numerous missing banisters. There are loose shards of basement floor tiles which are jagged and are potentially a hazardous material due to their age. The oven door had exposed broken glass. The lower-level storm door's broken panel has a sharp metal edge. The lint trap in the dryer had considerable buildup of material, which was emptied during inspection. | Floors, walls, ceilings and other surfaces shall be free of hazards. | A contractor has been secured to complete all permanent repairs, including replacement of the handrail and banisters, damaged flooring, oven door, and storm door panel. All corrective work is currently in progress.
Loose tile shards and debris were removed from the basement area. The dryer lint trap was fully cleaned during the inspection.
Staff were re-educated within the first four days of the inspection on home safety, fire prevention, and environmental hazard protocols, including routine appliance checks and proper lint trap maintenance after each dryer use. The agency's preventative maintenance plan will be followed to ensure hazards are identified and corrected promptly. |
01/09/2026
| Implemented |
| 6400.76(a) | The bed frame in Individual 1's bedroom is broken where the sides attach to the headboard. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The broken bed frame was immediately removed from the bedroom to eliminate any safety risk. Individual 1 was provided with a safe alternative sleeping arrangement which included being moved to a different residence. New, sturdy bedroom furniture will be ordered and installed once all ongoing repairs in the home are fully completed. |
01/06/2026
| Implemented |
| 6400.76(e) | There was no dining table or seating present in the home. | In homes serving eight or fewer individuals, there shall be dining tables with seating for all individuals at the same time. | The provider will purchase and install an appropriately sized dining table and sufficient chairs to accommodate all individuals residing in the home at one time. The dining area will be arranged to ensure it is accessible, safe, and suitable for shared meals. The dining table and seating will be purchased and installed once the repairs to the house have been completed |
01/19/2026
| Implemented |
| 6400.77(b) | The first aid kit was missing 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. | The first aid kit was replaced. Staff were educated on first aid kit requirements and the importance of maintaining complete emergency supplies at all times. A first aid kit inventory checklist will be implemented and reviewed monthly to ensure all required items remain available and in good condition. |
01/19/2026
| Implemented |
| 6400.82(f) | The bathroom did not contain hand soap, hand towels, or a trash can. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Hand soap, clean hand towels, and a trash can were immediately placed in the bathroom to ensure full compliance with regulatory requirements. Bathroom supply checks will be included in routine environmental inspections and shift checks to ensure all required items remain available at all times. |
01/12/2026
| Implemented |
| 6400.107 | There were four portable space heaters found in the garage. | Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including staff rooms.
| All portable space heaters were immediately removed from the home and are no longer stored or used on the premises. Heating concerns will be addressed only through approved, permanently installed heating systems. |
01/12/2026
| Implemented |
| 6400.111(c) | The fire extinguisher in the kitchen did not meet the minimum required 2A-10BC rating. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | The current kitchen fire extinguisher was replaced with a fire extinguisher that meets or exceeds the minimum required 2A-10BC rating. The new extinguisher will be properly mounted in the kitchen in an easily accessible location. fire safety requirements will be reviewed monthly and during routine safety checks to ensure all fire extinguishers meet required ratings and placement standards. Any noncompliant equipment will be replaced immediately. |
01/12/2026
| Implemented |
| 6400.144 | The following PRN medications were not present on-site: Acetaminophen 325mg tablets, Neosporin ointment, Cortisporin Otic Solution, Chlorpromazine 50mg tablets. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| The provider has reviewed the individual's current medication orders with the prescribing pharmacy to confirm which PRN medications are active and which have been discontinued.
All active PRN medications has been obtained and made available on-site immediately.
Any PRN medications that have been discontinued will be clearly documented in the individual's Medication Administration Record (MAR), including the date and authorizing provider.
All medications will be properly labeled, stored, disposed and documented in compliance with regulatory requirements. |
01/19/2026
| Implemented |
| 6400.163(h) | Individual 1's Ofolxacin 0.8% Otic course had ended 11/16/2025, but was still with their medications. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | The provider has reviewed the individual's current medication orders with the prescribing pharmacy to confirm which PRN medications are active and which have been discontinued.
All active PRN medications has been obtained and made available on-site immediately.
Any PRN medications that have been discontinued will be clearly documented in the individual's Medication Administration Record (MAR), including the date and authorizing provider.
All medications will be properly labeled, stored, disposed and documented in compliance with regulatory requirements. |
01/19/2026
| Implemented |