| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | On 8/20/25 at 10:17AM, a cabinet of unlocked poisonous cleaning supplies were in the laundry area of the home. The laundry room has a door that leads to Individual #1's bedroom. In the safety precaution section of Individual #1's individual, last updated on 8/15/25 reads, "[Individual #1] does not handle poisonous substances. She successfully completed Mr. Yuck program for poisonous substances in order to maintain safety precautions. It is not known if [Individual #1] would ingest these items, she wouldn't seek it out but if it was in a glass or inappropriate container and in the right place, she may ingest it. All poisonous materials are kept locked in her residential home." | Poisonous materials shall be kept locked or made inaccessible to individuals. | The Program Specialist requested the Supports Coordinator remove the locked poisons requirement from Individual's ISP on 9/15/25, based on her demonstrated safety and successful completion of poison identification training. |
09/15/2025
| Implemented |
| 6400.181(e)(9) | Individual #1's annual assessment, completed 6/13/2025, did not include functional and medical limitations. This section of the assessment stated, "Functional and medical limitations can be found in consumer's most recent physical." Individual #1's physical examination was not attached to the assessment or provided to the plan team as part of the assessment. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | The Program Specialist amended Individual's assessment on 8/28/25 to include functional and medical limitations and no longer relies on attachments.
The Compliance Officer conducted a company-wide review of all assessments to identify and remediate any similar omissions, with corrections completed by 9/1/25. |
09/01/2025
| Implemented |
| 6400.181(e)(12) | Individual #1's annual assessment, completed 6/13/2025, did not include recommendations for specific areas of training, programming and services. The assessment stated under Specific areas of training "Staff are trained in [Individual #1's] BSP, First Aid and CPR, Medication Administration" and under Recommended Programs/Services "Continued Residential Services; Continued Behavior Support Services." The assessment's recommendations were not specific to Individual #1. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The Program Specialist amended the assessment on 8/28/25 to include recommendations specific to Individual #1.
The Compliance Officer completed a company-wide review of all assessments to identify and remediate similar omissions, with corrections completed by 9/1/25. |
08/28/2025
| Implemented |
| 6400.182(c) | Individual #1's assessment, completed 6/13/2025, states "[Individual #1] can safely use and avoid poisonous materials. She will not seek them out to use. {Individual #1] is not at risk with avoiding poisonous materials. In the safety precaution section of Individual #1's support plan, last updated 8/15/2025, states "[Individual #1] does not handle poisonous substances. She successfully completed Mr. Yuck program for poisonous substances in order to maintain safety precautions. It is not known if [Individual #1] would ingest these items. She wouldn't seek it out but if in a glass or inappropriate container and in the right place, she may ingest it. All poisonous materials are kept locked in her residential home. Individual #1's assessment, completed 6/13/2025, states [Individual #1] can answer questions about heat sources correctly and is generally safe around them. In the general health and safety risks section of Individual #1's support plan, last updated 8/15/2025, states "[Individual #1] is not aware of heat sources. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The Program Specialist updated the assessment/ISP or requested revision on 8/28/25 for consistency.
The Compliance Officer conducted a company-wide review of assessments and ISPs to identify and remediate any similar inconsistencies, with corrections completed by 9/1/25. |
08/28/2025
| Implemented |