| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Individual #2's Service Plan, last updated 12/31/25, explains that Individual #2 has no unsupervised time around poisons, that Individual #2 would need supervision when utilizing such materials, and that Individual #2 has eaten soap, paper, and crayons in the past. At 2:58 PM on 3/17/26, unlocked and accessible in the closet located directly outside of Individual #2's bedroom at the end of the hallway were the following poisonous materials: three 32-ounce spray bottles of Great Value All-Purpose Cleaner with Bleach; a 17.5-ounce aerosol can of Raid Wasp and Hornet; and a 24-fluid-ounce bottle of Clorox Toilet Bowl Cleaner. [Repeated Violation-5/28/25] | Poisonous materials shall be kept locked or made inaccessible to individuals. | Door was locked immediately upon discovery by the present house staff. |
04/04/2026
| Implemented |
| 6400.104 | The home's undated Fire Department Notification Letter did not provide the exact bedroom locations of Individual #1 and Individual #2, who both require 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 locations given. This Fire Department Notification Letter read as follows: "[Individual #1] at the end of the hallway to the right is ambulatory but will require assistance to exit the home in case of an emergency. The bedroom on the left is now occupied by another individual [Individual #2] who is also ambulatory. [Individual #2] will also require assistance to exit the home in case of an emergency." | 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.
| CEO will resend a dated fire department notification letters with an attached floor plan documenting the exact location for the current 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 invoice provided for 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)(3) | Individual #1's date-of-birth is 1/19/49, and their date-of-admission is 10/11/20. Individual #1 did not complete a tetanus-diphtheria immunization, as recommended by the Centers for Disease Control. Individual #1's current physical examination, completed on 12/2/25, states, "Patient is medically exempt due to intolerance of vaccine." Individual #1's content of records did not include documentation of Individual #1's last completed tetanus-diphtheria immunization. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | The Program Specialist faxed the physician's office of who filled out the individuals physical requesting more detailed information on what the "intolerance" is. The Tetanus Diptheria Vaccination was last given on 11/27/2018 as noted in his ISP so no change was needed to stay in compliance of 10 years. No further information was given with his records when the individual transitioned into his home from another facility. |
03/28/2026
| Implemented |
| 6400.50(a) | On 3/17/25, Chief Executive Officer #1 self-attested to providing direct care services. On 7/1/25, 7/2/25, and 7/12/25, Chief Executive Officer #1 completed annual training for the 2025 calendar year on job-related knowledge and skills regarding individual-specific reviews of behavior support plans and service plans. However, this aforementioned training neither documented the trainer or facilitator who conducted the sessions, nor the training lengths, as the corresponding fields were left blank. Individual #1 completed annual fire safety training on 9/10/25. However, documentation for this fire safety training record did not include the trainer who facilitated the session. Individual #2 completed an initial fire safety training on 12/1/25. However, documentation for this fire safety training record did not include the trainer who facilitated the session. | 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. | Chief Executive Officer #1's training was signed by the trainer and the length of the training documented in the provided spaces on the training form. Individual#1's and Individual #2's fire safety training record was updated and signed by the trainer who facilitated the training.. |
03/23/2026
| Implemented |