| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(b) | At the time of the inspection on 9/22/26, there was a ping pong sized ball of lint in the dryer. | Floors, walls, ceilings and other surfaces shall be free of hazards. | This regulation is important because daily safe practices help maintain a safe home. At the time of the inspection on 9/22/26, there was ping pong ball sized ball of lint in the dryer. It occurred because the last person who used the dryer did not clean out the lint trap. The lint was removed by the licensing representative on the day of the onsite inspection. Education was provided and a sign was created and posted on the dryer that reads: PLEASE CLEAN LINT TRAP BEFORE AND AFTER EACH USE A FULL LINT TRAP IS A FIRE HAZARD THANK YOU. This task was added to the daily chore chart. |
10/02/2026
| Implemented |
| 6400.111(f) | The fire extinguishers were inspected on 7/11/25 and not again until 7/16/26, which is outside of the annual time frame. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | This regulation is important because it ensures that fully operational and easily accessible extinguishers are available in the event of a fire. The fire extinguishers were inspected on 7/11/2025 and not again until 7/16/2026 which is outside the annual time frame. This occurred due to a scheduling conflict with the fire expert. We notified the fire expert that we were cited with non-compliance due to it being outside the time frame. |
10/02/2026
| Implemented |
| 6400.112(d) | The evacuation time for the 4/3/26 fire drill was 2 minutes and 32 seconds, which exceeded the 2 minutes and 30 seconds time frame that individuals are to evacuate the house. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | This regulation is important because rapid evacuation within the maximum permissible time prevents fire-related death and injury. The evacuation time for the 4/3/26 was 2 minutes and 32 seconds, which exceeded the 2 minutes and 30 seconds time frame that individuals are to evacuate the house. Those responsible for completing drills have full understanding of the time requirement. It is also identified on the fire drill form. Aside from a transcription error, it very well may have exceeded the time requirement. This criteria is identified on the fire drill and instructs that an additional drill will be completed if it exceeds 2 minutes and 30 seconds. The plan to maintain compliance is that if the fire drill evacuation time exceeds 2 minutes and 30 seconds, then an additional drill will be completed. |
10/02/2026
| Implemented |
| 6400.141(c)(4) | Individual #2's physical dated 2/9/26 does not indicate a hearing screening occurred during the physical, this section is left blank on the form. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | This regulation is important because early medical information helps homes decide whether an individual's needs can be met at the home, helps the home develop accurate assessments and individual plans, and ensures that individuals' medical needs will be met. Individual # 2s physical dated 2/9/26 does not indicate a hearing screening occurred during the physical, this section is left blank on the form. Aside from this criteria being on the form, it was an oversite from the PCP and the staff that accompanied the individual. We reached out through the portal that a hearing screening be completed. |
10/02/2026
| Implemented |
| 6400.171 | At the time of the inspection on 9/22/26, there was a package of simply nature uncured beef hot dogs with a use by date of 9/17/26. | Food shall be protected from contamination while being stored, prepared, transported and served.
| This regulation is important because this prevents illnesses that are associated with contaminated food. At the time of the inspection on 9/22/26, there was a package of simply nature uncured beef hot dogs with a use by date of 9/17/26. This was missed during a check of expiration dates. The expired food was discarded on the day the licensing representative pulled it out of the refrigerator. A REFRIGERATOR ETTIQUETTE SIGN was placed on the refrigerator to remind to check expiration dates. |
10/02/2026
| Implemented |
| 6400.181(a) | Individual #1's assessment dated 4/30/26 did not include 181e10 (Lifetime Medical History).
Individual #2's assessment dated 4/30/26 does not identify 181e3(iv) (Personal needs with or without assistance) as this section was left blank and 181e4 (Need for supervision) as it only indicates that ongoing monitoring is necessary to discuss alone time adjustment in the community. The individual's actual current need for supervision is not documented.
Individual #1 and 2's assessments dated 4/30/26 do not include recommendations. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | This regulation is important because this ensures that providers fully understand individuals' needs and preferences to provide appropriate services and supports; balances self-direction, choice, and control with health and safety protection. On the assessment dated 4/30/26, the life time medical history wasn't attached. The Program Specialist didn't attach the life time medical history to the assessment. The lifetime medical history and the physical examination contents will be included as an attachment to the annual assessment for individual #1 and individual #2. Individual #2, the assessment was updated to document the missing information. |
10/02/2026
| Implemented |
| 6400.163(h) | At the time of the inspection, the following expired medications were in the home for Individual #2: Zinc oxide 20% ointment prescribed as apply a thin layer to cover skin at open areas 2x/day or after wiping off in routine cleaning expired 7/2026 and the medication Cetirizine 10mg tablet prescribed as take 1 tablet by mouth once daily at bedtime as needed for runny nose expired 5/13/25. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | This regulation is important because it prevents potential adverse reactions to expired or discontinued medication; reduces the chance of medication theft or misuse. At the time of the inspection, the following expired medications were in the home for Individual #2: Zinc oxide 20% ointment prescribed as apply a thin layer to cover skin at open area 2xda or after wiping off in routine cleaning expired 7/2026 and the medication Cetirizine 10 mg tablet prescribed as take 1 tablet by mouth once daily at bedtime as needed for runny nose expired 5/13/2025. Expired medications were not found during monthly cycle medication management. Medications were disposed the day of the on-site inspection. |
10/02/2026
| Implemented |
| 6400.181(f) | Individual #2's assessment was not sent to the team 30 days prior to the ISP meeting. The meeting was 6/4/26 and the assessment was not sent until 5/18/26. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | This regulation is important because it ensures that assessments are completed in a timely fashion and that notification assessment results are provided to all impacted parties. Individual #2s assessment was not sent to the team 30 days prior to isp meeting. The meeting was 6/4/26 and the isp was not sent until 5/18/26 (only 15 days prior). The Program Specialist was dealing with a serious health issue and it was missed by the Director as well. We recognize the importance of team orientation and will build in safeguards with Program Specialist and Director in the management of annual assessments. |
10/02/2026
| Implemented |
| 6400.183(b) | Individual #2's ISP meeting on 6/4/26 did not include at least 3 members of the individual plan team in addition to the individual. | At least three members of the individual plan team, in addition to the individual and persons designated by the individual, shall be present at a meeting at which the individual plan is developed or revised. | This is regulation is important because it ensures that the Individual Plan is person-centered, Individual driven, and full understood by all of the individual's natural and formal supports. Individual #2's ISP meeting on 6/4/26 did not include at least 3 members of the individual plan team in addition to the individual. The Program Specialist was dealing with a serious health issue and was in the ER during that time. The Director was with the Program Specialist. In hind-site, the Director should have contacted either the RN or a DSP to attend the meeting to meet the requirement. |
10/02/2026
| Implemented |