| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.103 | 103: Per the site records, the furnace at this location was cleaned on 06/30/2024 and 08/02/2025---more than one year apart. The furnace at this location was not cleaned annually as required. | Furnaces shall be cleaned at least annually. Written documentation of the cleaning shall be kept. | We were already cited on 6500.103 during August 2025 annual inspection. Below is our plan of correction for 8/2026
On 8/2/25, Furnace inspection was completed. As of 9/3/2025, the annual service date is recorded on the agency calendar to ensure that the furnaces are serviced on time. |
09/03/2025
| Implemented |
| 6500.109(h) | The 04/15/2026 fire drill record for this location did not note whether the individual residing in this home evacuated to the designated meeting place during the fire drill. The area of the form designated for this information was left blank. | Individuals shall evacuate to a designated meeting place outside the home during each fire drill. | On 06/15/2026, management held a meeting to discuss steps needed to ensure that fire drill forms are properly reviewed, and they meet 6500 regulations. |
06/15/2026
| Implemented |
| 6500.122(a) | Individual #1's Individual Record did not contain evidence that this individual had seen a dentist since admission to the provider's program on 01/12/2024. Per a "Case Note" authored by the provider's CEO and filed under "Dental" in the Individual Record, "[Individual #1] does not see any dentist because she has no teeth in her mouth." The absence of teeth in an individual does not absolve the provider of the requirement to ensure an individual receives annual dental examinations, which may include the checking of gums, a consultation for dentures, a visual oral inspection, and/or other examination components for an edentulous individual. This individual did not receive a dental examination at least annually as required. | An individual 17 years of age or younger, shall have a dental examination performed by a licensed dentist semiannually. Each individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Individual 1 will now have dental bi-annual exams and cleanings. His next appointment is scheduled for 7/24/2026. |
07/09/2026
| Implemented |