| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.63(a) | At 12:55PM, the hot water temperature measured 125°F at the sink in the bathroom on the second floor of the home. | 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. | Provider immediately turned down the temperature on the water heater during the on-site inspection once the concern was identified. Director of Development and Quality Management met with the House Supervisor on 9/8/25 to review the inspection results and explain the violation. Provider purchased a digital thermometer to read the water temperate on 9/9/25. Provider House Supervisor will be responsible for reading the water temperature once the thermometer is received via delivery on 9/12/25 and quarterly thereafter. |
09/09/2025
| Implemented |
| 6400.68(b) | At 12:55PM, the hot water temperature measured 125°F at the sink in the bathroom on the second floor of the home. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Provider immediately turned down the temperature on the water heater during the on-site inspection once the concern was identified. Director of Development and Quality Management met with the House Supervisor on 9/8/25 to review the inspection results and explain the violation. Provider purchased a digital thermometer to read the water temperate on 9/9/25. Provider House Supervisor will be responsible for reading the water temperature once the thermometer is received via delivery on 9/12/25 and quarterly thereafter. |
09/09/2025
| Implemented |
| 6400.141(c)(6) | Individual #1, date of admission 6/10/25, had an initial Tuberculin skin testing by Mantoux method on 8/20/25. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Provider updated the Admissions Individual Rights Policy to specifically outline what documentation must be obtained prior to an individual moving into the residential home. Director of Development and Quality Management met with Program Specialist and House Supervisor on 9/8/25 to review the licensing inspection results and details of this violation and to review the updated Admissions Individual Rights Policy with responsible staff members. |
09/08/2025
| Implemented |
| 6400.151(a) | Program Specialist #1, date of hire 6/10/25 had an initial physical examination completed 8/4/25. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Provider reviewed regulation with Director of Human Resources and HR Generalist on 8/22/2025 to ensure that all HR personnel responsible for hiring Residential staff understand that physical/TB must be completed prior to working with individuals. |
08/22/2025
| Implemented |
| 6400.151(c)(2) | Program Specialist #1, date of hire 6/10/25 had an initial Tuberculin skin testing by Mantoux method with negative result completed 8/4/25. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | Provider reviewed regulation with Director of Human Resources and HR Generalist on 8/22/2025 to ensure that all HR personnel responsible for hiring Residential staff understand that physical/TB must be completed prior to working with individuals. |
08/22/2025
| Implemented |
| 6400.181(b) | Individual #1 assessment, completed 8/1/25 indicated Individual #1 can independently watch tv or complete activities in the home for up to an hour without supervision. Individual #1's ISP updated 8/13/25 reads "[Individual #1] IS ABLE TO BE SAFELY LEFT ALONE FOR UP TO 4 HRS." Individual #1 assessment, completed 8/1/25 indicated Individual #1 can safely avoid head sources. Individual #1's ISP, updated 8/13/25 reads "[Individual #1] HAS SOME BASIC UNDERSTANDING OF HEAT SOURCES. WHILE IN THE KITCHEN, [Individual #1] NEEDS SUPERVISION. [Individual #1] REQUIRES CLOSE SUPERVISION WHEN IN THE KITCHEN." | If the program specialist is making a recommendation to revise a service or outcome in the individual plan, the individual shall have an assessment completed as required under this section. | Program Specialist reviewed and updated our current GCS Individual Assessment Template and made updates so that all sections of the regulatory compliance guide regarding the assessment are covered. Program Specialist revised the Individual Assessment for Individual #1 to correct the sections regarding independent time and safety around heat sources. The update indicates that Individual #1 requires someone to be in the home with him at all times, however, he is able to be alone in his room watching tv or completing other activities for up to one hour. The update also indicates that the individual is not safe around heat sources and requires close supervision while in the kitchen. Program Specialist emailed Individual #1's support coordinator on 9/10/25 to ensure that these updates are added to the individual's ISP. This email is filed in the individual's file for our records and proof of this communication. |
09/10/2025
| Implemented |
| 6400.181(f) | The program specialist did not provide Individual #2's initial assessment, completed 6/1/25 to plan team members for the annual ISP meeting on 7/21/25.
, | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Director of Quality Management and Development met with the Program Specialist on 9/8/25 to review the expectations for sending out Individual Assessments at least 30 calendar days prior to an ISP meeting. Individual #2's initial assessment was sent out on 9/10/25. |
09/10/2025
| Implemented |