| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(c) | The agency's self-assessment completed for this home on 9/26/25, did not provide a written summary of corrections and preventions made for the following regulation item identified as a violation: 6400.165g. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| Immediate Plan of action:
The corrections and preventions for violation 6400.165g were added to the Self Assessment by CEO on 10/8/25 |
10/15/2025
| Implemented |
| 6400.22(d)(1) | The agency is not Individual #1's and Individual #2's representative payee. Individual #1's Service Plan, last updated 5/19/25, states that "[Individual #1] does not fully understand the value of money to know how to budget and manage [their] finances." Individual #2's Service Plan, last updated 8/27/25, states that "[Individual #2] does not have the skills to manage [their] own money." However, on 10/7/25, the home did not keep an up-to-date financial and property record for Individual #1 and Individual #2 that included the following: personal possessions and funds received by or deposited with the family or home. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | Immediate Plan of action:
List of Personal Property:
The Participant Program binder in Section 3 contains all inventory of personal property. All participant program binders were at RMPC's Main office for licensing. That binder has since been placed back at the site for Individual #1 and Individual #2.
Financial Record:
Individual #1 and Individual # 2 MCI(5306474825) have representative payee services through Ursuline support Services. Their financial records are electronic and can be accessed through Truelink. Both individuals have debit cards. Individual 1 does not keep his debit card on his person, that is his preference his debit card is kept in his money pouch at site. Individual 2 however has chosen to keep his debit card on his person.
While on site we showed the licensing rep both transaction reports which also showed the current balance.
Individual 1 also had petty cash at the site and there was a paper ledger to show the licensing rep. |
10/15/2025
| Implemented |
| 6400.22(d)(2) | The agency is not Individual #1's and Individual #2's representative payee. Individual #1's Service Plan, last updated 5/19/25, states that "[Individual #1] does not fully understand the value of money to know how to budget and manage [their] finances." Individual #2's Service Plan, last updated 8/27/25, states that "[Individual #2] does not have the skills to manage [their] own money." However, on 10/7/25, the home did not keep an up-to-date financial and property record that included the following: disbursements made to or for Individual #1 and Individual #2. | (2) Disbursements made to or for the individual.
| Immediate Plan of action:
Individual #1 MCI (001667998) and Individual # 2MCI(5306474825) have representative payee services through Ursuline support Services. Their financial records are electronic and can be accessed through Truelink. Both individuals have debit cards. Individual 1 does not keep his debit card on his person, that is his preference his debit card is kept in his money pouch at site. Individual 2 however has chosen to keep his debit card on his person.
While on site we showed the licensing rep both transaction reports which also showed the current balance in addition to deposit and purchase history. They were not printed out but were shown via desktop computer at the site.
Individual 1 MCI(001667998) also had petty cash at the site and there was a paper ledger to show the licensing rep.
*See emailed supporting documents related to this violation
Individual 1 has recurring deposits that are dispersed from his rep payee every 2nd tuesday and 4th tuesday of the month
Individual 2 has recurring deposits that are dispersed from his rep payee every 2nd tuesday and 4th tuesday of the month |
10/15/2025
| Implemented |
| 6400.63(a) | At 1:10 PM on 10/7/25, the hot water temperature at the kitchen sink measured 125.2 degrees Fahrenheit. At 1:15 PM on 10/7/25, the hot water temperature at the sink in the full bathroom located on the home's first floor measured 125.2 degrees Fahrenheit. | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | Immediate Plan of action:
The hot water tank was lowered by the CEO during the inspection on 10/7/25. Staff began to get readings between 116-118 later that evening when the participants came back home from their programs. |
10/15/2025
| Implemented |
| 6400.66 | At 1:24 PM on 10/7/25, the enclosed rear deck outside of the exterior sliding glass door of Individual #1's bedroom and the exterior door of the home's den did not have a lighting source for safety and illumination for leisure activities. At 1:49 PM, the lighting fixture outside of the attached garage and adjacent to game room exterior exit was inoperable, and there was no sufficient lighting source nearby. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| mmediate Plan of action:
A light fixture was installed on the back deck area by RMPC maintenance team on 10/15/25. The light fixture outside the attached garage was also replaced on 10/15/25.
*See emailed supporting documentation photos. |
10/14/2025
| Implemented |
| 6400.68(b) | At 1:55 PM on 10/7/25, the hot water temperature at the tub in the full bathroom located on the home's second floor measured 124.8 degrees Fahrenheit. [Repeated Violation-10/8/24, et al] | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Immediate Plan of action:
The hot water tank was lowered by the CEO during the inspection on 10/7/25. Staff began to get readings between 116-118 later that evening when the participants came back home from their programs. |
10/14/2025
| Implemented |
| 6400.80(b) | At 1:30 PM on 10/7/25, there was metal chicken wire attached to the exterior mesh of the screen door leading from the game room to the rear yard. However, the chicken wire was not attached to the screen door mesh in a flush manner and sagged outward by approximately four inches from the structure, exposing sharp points. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | Immediate Plan of action:
On 10/14/24 the chicken wire was removed by RMPC maintenance team.
*See emailed supporting documents |
10/14/2025
| Implemented |
| 6400.101 | At 1:43 PM on 10/7/25, the game room's interior door leading to the attached garage was equipped with a privacy lock having a pop mechanism on the game room side and no access point in which to disengage it from the garage side. The attached garage did not have an exterior door to prevent entrapment. [Repeated Violation-10/8/24, et al] | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Immediate Plan of action:
A new door knob without a locking mechanism was replaced on 10/14/25 by the RMPC maintenance Team. The door knob on the game room door is extremely old and we weren't even aware they could lock. This knob has been on the gameroom door for all of our licensings dating back to 2013. |
10/14/2025
| Implemented |
| 6400.214(b) | At 2:20 PM on 10/7/25, neither hard nor electronic copies of the following regarding Individual #1's most current records were kept at the home: an applicable psychological evaluation. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| Immediate Plan of action:
The Participant Program binder in Section 7 contains psychological evaluations past and present.The program binders were at the main office for licensing. To correct this violation immediately the binder was taken back to the site on 10/7/25 by PS. In addition an electronic copy of the psychological evaluation was scanned to individual 1's google drive folder by the PS. |
10/13/2025
| Implemented |
| 6400.32(h) | Three individuals currently reside at the home. At 1:27 PM on 10/7/25, the full bathroom on the home's main level had two entries: one which leads from the bedroom hallway and one which leads from Individual #1's bedroom. However, the bathroom's entry from Individual #1's bedroom was missing a door or partition wall, therefore, infringing upon privacy. | An individual has the right to privacy of person and possessions. | Immediate Plan of action:
On 10/14/25 a sliding partition door was installed by RMPC Maintenance Team leading from bathroom to bedroom to provide more privacy for Individual 1.
See photos sent via email. |
10/16/2025
| Implemented |
| 6400.32(r)(1) | At 1:23 PM on 10/7/25, the door to Individual #1's bedroom was equipped with a privacy lock having a pop mechanism on the inside and a push-pinhole access point on the entry side. Individual #1 does not have a mechanism or entry device to lock and unlock their 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 lock and unlock the door. | Immediate Plan of action:
A new door knob without a locking mechanism for individual 1 bedroom was replaced on 10/14/25. Individual 1 previously decided that he does not want a lock on his bedroom door. A Lock Declination form was completed for MG to show it was his choice to have no locking mechanism. The door knobs on his bedroom door were extremely old knobs and we weren't even aware they could lock. They have been on that bedroom door for all of our licensings dating back to 2013. |
10/16/2025
| Implemented |
| 6400.32(r)(4) | At 1:23 PM on 10/7/25, the door to Individual #1's bedroom was equipped with privacy lock having a pop mechanism on the inside and a push-pinhole access point on the entry side. This bedroom door locking system does not allow easy and immediate access by the individual and staff persons in the event of an emergency. | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. | Immediate Plan of action:
A new door knob without a locking mechanism for individual 1 bedroom was replaced on 10/14/25. Individual 1 previously decided that he does not want a lock on his bedroom door. A Lock Declination form was completed for MG to show it was his choice to have no locking mechanism. The door knobs on his bedroom door were extremely old knobs and we weren't even aware they could lock. They have been on that bedroom door for all of our licensings dating back to 2013. |
10/16/2025
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medication to treat symptoms of a psychiatric illness. The medication reviews completed on the following dates were not conducted by a licensed physician, but rather by a non-prescribing Registered Nurse: 11/26/24, 3/28/25, and 7/28/25. In addition, the medication reviews completed by a licensed physician on 1/29/25 and 8/26/25, did not include the reason for prescribing the medication, as the corresponding fields were left blank. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Immediate Plan of action:
RMPC provides a Med Review Form for physicians to fill out and was created in accordance to regulation 165g.Initally we would prepopulate the form based on the medications the individual was currently prescribed and this would alleviate any issues of physicians not filling out the form properly. However, In our south eastern region licensing we were told we could not pre-populate the med review form so we stopped doing so. With this current licensing in western region we were told that it is ok to prepopulate the form to ensure you get the necessary information to satisfy the regulatory requirements. With that RMPC will go back to pre populating our med review forms in the western region. In addition the med review form was updated by the CEO to include the statement that RN nor LPN can sign off on the medication reviews. |
10/14/2025
| Implemented |
| 6400.182(c) | Individual #1's Service Plan, last updated 5/19/25, contained the following discrepancies between their current assessment, completed on 2/1/25, in the following health and safety skill domains: regarding poisonous materials, Individual #1's Service Plan, last updated 5/19/25, stated "[Individual #1] knows the meaning of Mr. Yuk stickers and would not ingest any poisonous substances if left unattended. [Individual #1] requires verbal assistance···when around chemicals or poisonous substances, if not identified properly identified with stickers." However, Individual #1's assessment, completed on 2/1/25, indicated, "Yes," in relation to Individual #1 having the independent ability to safely use and avoid poisonous materials; regarding supervision within the home, Individual #1's Service Plan, last updated 5/19/25, explained that they require 24-hour supervision with a 1:2 staffing ratio, that "[Individual #1] is always supervised due to safety concerns and recent behavioral issues, [and] [that] [Individual #1] needs supervision in the bathroom and kitchen." In contrast, Individual #1's assessment, completed on 2/1/25, informed that Individual #1 does not spend alone without supervision and that Individual #1 is not safe around harmful substances; and regarding supervision within the community, Individual #1's Service Plan, last updated 5/19/25, stated that they need 24- supervision with a 1:2-3 staffing ratio, that "[Individual #1] requires close supervision in the community because···[they] tend to get lost, [and] [that] [Individual #1] needs physical and verbal assistance to maintain safety in traffic." However, Individual #1's assessment, completed on 2/1/25, indicated that they require total supervision in the community because of safety needs, such as crossing streets and stranger awareness. Individual #2's Service Plan, last updated 8/27/25, contained the following discrepancies between their current assessment, completed on 5/27/25, in the following health and safety skill domain: regarding fire evacuation, Individual #2's Service Plan, last updated 8/27/25, reads "[Individual #2] has a general understanding of fire safety, and there are smoke detectors in [their] home. [Individual #2] requires verbal prompts to evacuate. In contrast, Individual #2's current assessment, completed on 5/27/25, states that Individual #2 is independent with fire evacuation. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Immediate Plan of action:
To correct this violation individual 1's assessment was updated by the Ps on 10/13/25 to reflect the current needs of the individual with input form dcsp's, the participant and other plan team members. Any information that was not accurate in the ISP was sent to the SC to be updated to reflect the same information updated in the residential assessment. This notification was sent via email. PS will follow up with the SC weekly to ensure the revisions were submitted for approval.
*Updated Individual 1 assessment and proof sc notification will be sent as supporting documentation.
To correct this violation individual 2's assessment was updated by the PS on 10/9/25 to reflect the current needs of the individual with input form dcsp's, the participant and other plan team members. Any information that was not accurate in the ISP was sent to the SC to be updated to reflect the same information updated in the residential assessment. This notification was sent via email. PS will follow up with the SC weekly to ensure the revisions were submitted for approval.
Updated Individual 2 assessment and proof sc notification will be sent as supporting documentation. |
10/15/2025
| Implemented |