| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | The left knob was missing on the closet in the living room. The left bathroom tub knob was loose and came off during the inspection. The bathtub water would not turn on, and agency staff had to come and repair the knob so that the hot water would turn on. Even after the agency staff were able to get the knob to function it was loose and wobbled when touched. | Floors, walls, ceilings and other surfaces shall be in good repair. | Agency maintenance fixed the issue immediately after inspection. |
07/12/2025
| Implemented |
| 6400.72(b) | The screen door leading to the patio had approximately 7 tears in the screen varying in size and shape. | Screens, windows and doors shall be in good repair. | Screen door was replaced on 7.15.25 by agency maintenance, |
07/15/2025
| Implemented |
| 6400.77(b) | At the time of the inspection the first aid kit did not contain tape. | 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. | New first aid kit were bought by manager to ensure compliance. |
07/12/2025
| Implemented |
| 6400.142(c) | Individual #1 had a dental examination completed however the form did not include the date the examination was performed. | A written record of the dental examination, including the date of the examination, the dentist's name, procedures completed and follow-up treatment recommended, shall be kept. | Nurse retrained staff on properly fill appointments form on 7.20.25 |
07/20/2025
| Implemented |
| 6400.181(e)(14) | Individual #1's assessment dated 4/15/25 did not include the individual's knowledge of water safety such as the ability to regulate their own water in the home. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | Program specialist corrected the information on 7.12.25 |
07/12/2025
| Implemented |
| 6400.34(a) | Individual #1 was informed of his rights on 2/15/2025. The rights haven't been updated to reflect the current Chapter 6400 regulations. The missing rights include: An individual may not be discriminated against because of race, color, creed, disability, religious affiliation, ancestry, gender, gender identity, sexual orientation, national origin, or age, individual may not be exploited or abandoned, shall be treated with dignity and respect, make choices and accept risks, refuse to participate in activities and services, control his own schedule and activities, privacy of person and possessions, receive scheduled and unscheduled visitors at any time, access to other forms of communications, unopened and unread by others, including the right to share contact information with whom the individual chooses, choose persons with whom to share a bedroom, furnish and decorate the individual's bedroom and the common areas of the home in accordance with § 6400.33, lock the individual's bedroom door, Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to unlock and lock the door, access to an individual's bedroom shall be provided only in a life-safety emergency or with the express permission of the individual for each incidence of access, assistive technology shall be provided as needed to allow the individual to open and lock the door without assistance, the locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency, direct service workers who provide services shall have the key or entry device to lock and unlock the door, right to have a key, access card, keypad code, or other entry mechanism to lock and unlock an entrance door of the home, access food at any time, make health care decisions, and an individual's right may only be modified in accordance with § 6400.185 (relating to content of individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Rights information updated on 7/12.25 by CEO |
07/12/2025
| Implemented |
| 6400.195(a) | At the time of the inspection all the sharps were locked in the office/second bedroom in a locked toolbox at the time of the inspection. The only telephone in the home was also locked in the office/second bedroom in the home. The provider is implementing a restrictive procedure without a behavior support plan reviewed by a human rights team that addresses the need for the restrictive procedure. | For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures. | A new bsp was created by agency behavior specialist to ensure compliance. |
07/24/2025
| Implemented |
| 6400.195(c)(8) | Individual #1's date of admission is 2/15/25 and they had a Restrictive Procedure Plan (RPP) from their prior agency dated 9/23/24 and that that Behavior Specialist and another Assistant Clinical Coordinator/Behavior Specialist at that agency were responsible for monitoring the plan and collecting data. However, since Individual #1 moved to Community Initiative Group the staff identified in the RPP dated 9/23/24 from the other agency have not seen or been monitoring and documenting the behavior support component of the individual plan. | The behavior support component of the individual plan shall include: The name of the staff person responsible for monitoring and documenting progress with the behavior support component of the individual plan. | Individual restriction will be review by HR Committee twice a year to ensure compliance CEO will ensure only restrictions on are addressed. |
07/24/2025
| Implemented |