| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Individual #2's Service Plan, last updated 1/16/2026, stated, "[Individual #2] knows that a Mr. Yuk sticker means not to touch or drink. [Individual #2] does not bother with poisonous substances with stickers on them. Team does not know what [they] would do without sticker. Staff says [Individual #2] might pick up poisonous substances to see what they are but will not ingest them. Poisonous substances are in locked area at [their] residence." At 1:58 PM on 6/18/2026, unlocked and accessible in a closet located on the right in the home's bedroom hallway was a 1.25-liter container of Swiffer Wet Jet anti-bacterial mop solution with instructions to "Contact Poison Control Center," if ingested or exposed. At 2:12 PM, unlocked and accessible on an open shelf located in the home's attached garage were three 123 fluid-ounce cans of Sherman Williams paint, one 124 fluid-ounce can of Valspar paint and primer, and one one-gallon can of Valspar ceiling paint. At 2:16 PM, unlocked and accessible underneath the vanity sink of the full bathroom located in the home's game room was an 85-count container of Clorox disinfecting wipes. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The poisonous materials identified as being in unlocked areas were moved into the locked cleaning cabinets of the home on 6/19/26. Staff members working in the home were provided with reminders on the Teams app Channel Chat on 6/19/26, to ensure that all poisonous materials remain in locked areas at all times. |
06/19/2026
| Implemented |
| 6400.72(a) | At 1:55 PM on 6/18/2026, the operable front window located on the right side of the home's enclosed front porch had an accordion screen installed in its opening. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Accordion screen was kept in the window until the replacement was able to be installed. A sign was placed on the window on 6/19/26 to designate it as inoperable until the appropriate screen was able to be placed.
Program specialist ordered a new screen that was placed and secure in the window on 7/3/26. |
07/03/2026
| Implemented |
| 6400.101 | At 2:10 PM on 6/18/2026, the interior game room door leading to the home's attached garage was equipped with both a standard door lock assembly and deadbolt, requiring a key to disengage them from the garage side. Since the attached garage did not have an exterior swing door, an entrapment area existed within this area. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| On Wednesday 6/24/26, under the instruction of the Program Specialist, the House Supervisor turned both locks around to ensure that the key lock mechanism was not on the garage side of the door. The garage side of the door now has the turn lock instead of the key lock so that there is no risk of entrapment. All direct service workers were informed of this change via message in the Microsoft Teams channel that is used for communication on 6/24/26. |
06/24/2026
| Implemented |
| 6400.106 | The home's furnace was inspected and cleaned on 8/30/2024. The home's next furnace inspection was completed on 4/20/2026, and did not include a cleaning, as the invoice work summary from the servicing company read, "Didn't clean flame sensor rod along with the condensation trap and condensation pump." The invoice included neither a notation that the furnace's blower component was cleaned, nor that its air filter was replaced, as this same servicing company's 8/30/2024 invoice had indicated. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| Program Specialist requested updated communication from the company that provided the inspection and cleaning to confirm that a cleaning was complete. A response was received on 6/24/26 that indicates that there was cleaning performed on the parts that required it.
SouthSide Plumbing provided Program Specialist with an email stating: "Based on our recent phone conversation regarding the annual furnace cleaning and inspection of the Bryant forced air furnace Model # 915SA48080S17A-A, and as reflected on Invoice # I8949. At your request I reached out to the technician that performed the cleaning and inspection whom confirmed the furnace was in a condition that did not warrant a thorough cleaning as would be the case with a furnace not well maintained. The language within his write up indicates the flame sensor rod was not cleaned as no carbon buildup was present. He did clean the blower compartment, blower motor and similar ancillary components that required attention. Photographs were attached to depict conditions post cleaning which appear favorable." This email communication has been documented and placed on file for the home with the initial inspection and cleaning. |
06/24/2026
| Implemented |
| 6400.112(c) | According to the written fire drill record submitted from September 2025 to May 2026, the following drills did not document the required information accordingly: the drill conducted on 11/17/2025 did not indicate the exact time it took to evacuate, and the drill conducted on 2/26/2026 did not indicate if the fire alarm or smoke detector was operative. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Staff members in the home were provided with an updated Fire Safety Training that reviewed fire drills and fire safety in the home on 6/1/26. Staff members were provided with additional reminders that included: ensuring all questions are responded to on the fire drill forms, all times are exact, and if the alarms were operable- this was sent on 7/1/26 via the Teams app Channel Chat. The fire drill log template was updated 7/1/26 to ensure easier reading and responding to all required components. |
07/01/2026
| Implemented |
| 6400.113(a) | Individual #1's date-of-admission 6/10/2025. However, Individual #1 completed initial fire safety training on 7/27/2025. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | Program Specialist met with the House Supervisor on 6/24/26 to review the results of this inspection. During this meeting, it was discussed that all individuals need to be trained on fire safety annually and that training cannot exceed 365 days. Individual #1 and Individual #2 have current fire safety trainings completed as of 4/16/26 when an annual updated training was completed with the individuals by the House Supervisor. |
06/24/2026
| Implemented |
| 6400.141(a) | Individual #1's date-of-admission is 6/10/2025. However, the only physical examination contained within Individual #1's content of records was completed on 6/26/2025. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Program Specialist met with the House Supervisor on 6/24/26 to review the results of this inspection. During this meeting, the regulations and expectations that all individuals have a physical before they move-in and yearly thereafter was discussed. Individual #1's most recent physical was completed on 7/1/26 and is on file. |
06/24/2026
| Implemented |
| 6400.141(c)(3) | Individual #1's date-of-birth is 9/20/1978. Individual #1's initial current physical examination, completed on 6/26/2025, did not include a record of immunizations documenting Individual #1's receipt of a tetanus-diphtheria vaccination, as the corresponding field was left blank. In addition, Individual #1's content-of-records included a record of immunizations that did not document if or when Individual #1 had last been administered a tetanus-diphtheria vaccination. On 6/18/2026, agency interviews explained that Individual #1 has an allergy to the tetanus-diphtheria vaccination. However, Individual #1's content-of-records included neither documentation from a physician verifying such a contraindication to the tetanus-diphtheria vaccination, nor a regulatory waiver from the Department for exemption from this immunization. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Program Specialist met with the House Supervisor on 6/24/26 to review the results of this inspection. During this meeting, the regulations and expectations were reviewed that all individuals have up to date immunizations and that any exemptions from immunizations are documented properly. Individual #1 had a completed Tetanus/ Diphtheria on 3/1/2002. Individual #1s parent was contacted on 6/19/26 and reported that Individual #1 had a TDAP allergy and was not able to receive this vaccination, however, was not able to provide any medical documentation of the allergy. During Individual #1s annual physical, his doctor provided the Program Specialist with a referral for an allergist to test for TDAP allergy. Doctor reported that no documentation was provided showing the allergy that was reported by the parent.
Individual #1 obtained a referral to an allergist by physician on 7/1/26 and a request for an appointment scheduling phone call was placed on 7/2/26. It was not possible to schedule with the allergist directly through the scheduling line that was provided. The Program Specialist was notified that the allergist would call them to schedule an appointment. Program Specialist contacted the allergist's office direct line on 7/3/26 and it was closed. |
07/03/2026
| Implemented |
| 6400.141(c)(4) | Individual #2's current physical examination, completed on 10/14/2025, did not include vision or hearing screenings, as the physician indicated "N/A" under the corresponding fields. Individual #2's most recent vision and hearing screenings were last completed at their physical examination conducted on 10/29/2024. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Program Specialist met with the House Supervisor on 6/24/26 to review the results of this inspection. During this meeting, the regulations and expectations were reviewed that all individuals have up to date hearing and vision screenings and that they are documented properly (ie. Listing N/A is not permitted).
Program Specialist and House Manager contacted Individual #1 and #2 physicians on 7/2/2026 to schedule follow up physical exams so that vision and hearing screenings could be completed. Program Specialist was instructed to fax the physical forms to the respective offices with requests for updates needed indicated in the fax. Program Specialist had both physicals sent to the respective offices on 7/3/2026 with specific instructions on how each section should be filled out. |
07/03/2026
| Implemented |
| 6400.141(c)(10) | Individual #1's date-of-admission is 6/10/2025. Individual #1's initial and current physical examination, completed on 6/26/2025, did not indicate if Individual #1 is free of communicable disease, as the corresponding field read, "Is the person free of communicable disease? Yes or No." However, the response was unmarked. Individual #1's date-of-admission is 6/10/2025. Individual #2's current physical examination, completed on 10/14/2025, did not indicate if Individual #2 is free of communicable disease, as the corresponding field read, "Is the person free of communicable disease? Yes or No." However, the response was unmarked. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | Individual #1 received an updated physical, that includes the completion of this section, on 7/1/26.
Individual #2 visited the doctor with staff member on 6/25/26 to review the physical form and be provided with needed updates. This section was complete during this visit. A meeting was held with the House Supervisor and Program Specialist discussed the results of this inspection and reviewed the expectations of physical exam including ensuring that the box for communicable diseases is checked. This was completed on 6/24/26. |
07/01/2026
| Implemented |
| 6400.141(c)(12) | Individual #2's current physical examination, completed on 10/14/2025, did not address physical limitations of the individual, as the corresponding field was left blank. | The physical examination shall include: Physical limitations of the individual. | A meeting was held with the House Supervisor on 6/24/26 and Program Specialist discussed the results of this inspection and reviewed the expectations of physical exam including ensuring that the box for physical limitations is checked. The updated physical for Individual #2 was completed on 6/25/26. |
06/25/2026
| Implemented |
| 6400.141(c)(14) | Individual #2's current physical examination, completed on 10/14/2025, did not include medical information pertinent to diagnosis and treatment in case of an emergency, as the corresponding field was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | A meeting was held with the House Supervisor on 6/24/26 and Program Specialist discussed the results of this inspection and reviewed the expectations of physical exam including ensuring that the necessary information regarding diagnoses and emergency treatment is provided/present on the form. The updated physical for Individual #2 was completed on 6/25/26. |
06/25/2026
| Implemented |
| 6400.141(c)(15) | Individual #2's current physical examination, completed on 10/14/2025, did not include special instructions for the individual's diet, as the corresponding field was left blank. | The physical examination shall include:Special instructions for the individual's diet. | A meeting was held with the House Supervisor on 6/24/26 and Program Specialist discussed the results of this inspection and reviewed the expectations of physical exam including ensuring that the necessary information regarding the individual's diet is provided/present on the form. The updated physical for Individual #2 was completed on 6/25/26. |
06/25/2026
| Implemented |
| 6400.151(a) | Direct Service Worker #6's date-of-hire is 5/21/2025. However, Direct Service Worker #6 had an initial physical examination completed on 5/30/2025. | 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. | Direct Service worker #6 had a physical examination and TB test completed and read on 5/30/2025 showing that she was able to work in this setting. A meeting was held with Director of Human Resources, Director of Operations, Director of Quality Management, Program Specialist, and CEO on 6/29/26 to review the components of this violation. Director of Human Resources was made aware that Direct Service Worker #6 received a violation and her personnel file was checked to ensure that the physical exam was completed on 5/30/2025 and is now in compliance. |
06/30/2026
| Implemented |
| 6400.151(c)(2) | Direct Service Worker #6's date-of-hire is 5/21/2025. However, Direct Service Worker #6 had an initial tuberculin skin test via Mantoux method read with negative results on 5/30/2025. | 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. | Direct Service worker #6 had a physical examination and TB test completed and read on 5/30/2025 showing that she was able to work in this setting. A meeting was held with Director of Human Resources, Director of Operations, Director of Quality Management, Program Specialist, and CEO on 6/29/26 to review the components of this violation. Director of Human Resources was made aware that Direct Service Worker #6 received a violation and her personnel file was checked to ensure that a TB test was completed on 5/30/2025 and is now in compliance. |
06/30/2026
| Implemented |
| 6400.181(a) | Individual #1's date-of-admission is 6/10/2025. However, individual #1's initial assessment was completed on 8/20/2025. Individual #2's date-of-admission is 4/8/2025. However, Individual #2's initial assessment was completed on 8/20/2025. | 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. | Program Specialist reviewed and updated the Transition Planning Tool on 7/2/26 to include the beginning/review of the Individual Assessment during the transition process, rather than beginning after move-in. Program Specialist reviewed the individual tracking sheet to ensure that the timeline requirements for initial individual assessments is noted for tracking purposes. |
07/02/2026
| Implemented |
| 6400.181(c) | Individual #2's current assessment, completed on 8/20/2025, was not based on assessment instruments, interviews, progress notes, and observations, but rather on Individual #2's Service Plan, as was explicitly stated therein, regarding their lifetime medical history and read as follows: "According to the 2025-2026 ISP [Individual #2] seemed to be normal at birth. [They] walked on time but was delayed in speaking. Around age 3 [Individual #2] started to have behaviors." | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | Program specialist reviewed and updated the lifetime medical history to ensure that information is independent from the individual support plan. House Manager conducted an interview with Individual #2's only family member/natural support on 7/3/26 to obtain additional health information. Information from the HRST was also included in this assessment. |
07/03/2026
| Implemented |
| 6400.181(e)(4) | Individual #1's current assessment, completed on 5/28/2026, did not address their community supervision needs, as there was neither a corresponding field, nor such information contained elsewhere in the document. | The assessment must include the following information: The individual's need for supervision.
| Program Specialist reviewed Individual #1's Assessment on 6/24/2026 to update supervision needs to include home and community supervision needs.
Program Specialist updated the Individual Assessment template on 7/2/26 to include *(in the home and in the community) * under the supervision needs section.
Program Specialist sent the updated assessment to Individual #1's Supports Coordinator with changes needed specified. This was sent on 7/3/26. |
07/03/2026
| Implemented |
| 6400.34(a) | Individual #1's date-of-admission is 6/10/2025. However, Individual #1 was initially informed and explained individual rights on 7/31/2025. Individual #2 was informed and explained individual rights on 3/18/2025, and then again on 4/1/2026. | 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. | A meeting was held with Director of Human Resources, Director of Operations, Director of Quality Management, Program Specialist, and CEO on 6/29/26 to review the components of this violation. It was determined during this meeting that Individual #1 has an up-to-date individual rights sign off sheet reviewed/dated on 7/31/2025. Individual #2 has an up-to-date individual rights sign off sheet reviewed/ dated 4/1/2026. |
06/29/2026
| Implemented |
| 6400.50(a) | Chief Executive Officer #1's annual training for the 2025 calendar year did not document the course lengths for the following training completed 10/13/2025: the application of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships; and recognizing and reporting incidents. House Supervisor #2's date-of-hire is 6/6/2025. House Supervisor #2's orientation did not document the course lengths for the following trainings on the corresponding dates: the application of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships on 10/22/2025; recognizing and reporting incidents on 10/22/2025; and individual-specific plan reviews relative to the safe and appropriate use of behavior supports as well as to implementation of the individual service plan on 7/23/2025. In addition, House Supervisor #2's current fire safety training, completed on 7/23/2025, did not document the course length and the trainer(s) of the site-specific requirements. Direct Service Worker #3's date-of-hire is 4/7/2025. Direct Service Worker #3's orientation did not document the course lengths for the following trainings on the corresponding dates: the application of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships on 11/12/2025; recognizing and reporting incidents on 11/12/2025; and individual-specific plan reviews relative to the safe and appropriate use of behavior supports as well as to implementation of the individual service plan on 4/7/2025. In addition, Direct Service Worker #3's fire safety training, completed on 4/7/2025, did not document the course length and the trainer(s) of site-specific requirements. Program Specialist #4's date-of-hire is 6/10/2025. Program Specialist #4's orientation training did not document the completion dates and trainer(s) for the following trainings: recognizing and reporting incidents; and job-related knowledge and skills regarding individual-specific plan reviews relative to the safe and appropriate use of behavior supports as well as to implementation of the individual service plan. In addition, Program Specialist #4's fire safety training did not document the completion date and the trainer(s) site-specific requirement. Direct Service Worker #5's date-of-hire is 4/7/2025. Direct Service Worker #5' s orientation training did not document the completion dates and trainer(s) for the following trainings: job-related knowledge and skills regarding individual-specific plan reviews relative to the safe and appropriate use of behavior supports as well as to implementation of the individual service plan. In addition, Direct Service Worker #5's fire safety training did not document the completion date and the trainer(s) site-specific requirements. Direct Service Worker #6's date-of-hire is 5/21/2025. Direct Service Worker #6' s orientation training did not document the completion dates and trainer(s) for the following trainings; job-related knowledge and skills regarding individual-specific plan reviews relative to the safe and appropriate use of behavior supports as well as to implementation of the individual service plan. In addition, Direct Service Worker #6's fire safety training did not document the completion date and the trainer(s) site-specific requirements. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | A meeting was held with Director of Human Resources, Director of Operations, Director of Quality Management, Program Specialist, and CEO on 6/29/26 to review the components of this violation. The team discussed the deficiencies in our current training tracking system and reviewed the regulations outlined in 6400.50.a. |
06/29/2026
| Implemented |
| 6400.51(b)(1) | Owner/ Chief Executive Officer #1's annual training for the 2025 calendar year documented a cumulative of 5.0 completed hours out of the 12.0 total hours required annually for this position. | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | A meeting was held with Director of Human Resources, Director of Operations, Director of Quality Management, Program Specialist, and CEO on 6/29/26 to review the components of this violation. The team discussed the deficiencies in our current training tracking system and reviewed the regulations outlined in 6400.51.b.1 as it pertains to our orientation process. Director of Human Resources created a new Residential New Hire training checklist to ensure that newly hired direct service workers have all required orientation trainings completed prior to working with individuals. The checklist was created on 7/1/2026. |
07/01/2026
| Implemented |
| 6400.51(b)(2) | House Supervisor #2's date-of-hire is 6/6/2025. For the required training topic on the prevention, detection and reporting of abuse, suspected abuse, and alleged abuse, House Supervisor #2's orientation revealed that House Supervisor #2 had only completed the Department's course entitled, "Addressing Day to Day Risks with the Team," on 9/23/2025. However, this session does not incorporate all the required components under the topic on abuse. Direct Service Worker #3's date-of-hire is 4/7/2025. For the required training topic on the prevention, detection and reporting of abuse, suspected abuse, and alleged abuse, Direct Service Worker #3's orientation revealed that Direct Service Worker #3 had only completed the Department's course entitled, "Addressing Day to Day Risks with the Team," on 9/10/2025. However, this session does not incorporate all the required components under the topic on abuse. Program Specialist #4's date-of-hire is 6/10/2025. For the required training topic on the prevention, detection and reporting of abuse, suspected abuse, and alleged abuse, Program Specialist #4's orientation revealed that Program Specialist #4 had only completed the Department's course entitled, "Addressing Day to Day Risks with the Team," on 9/10/2025. However, this session does not incorporate all the required components under the topic on abuse. | The orientation must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§10225.101-10225.5102). The child protective services law (23 PA. C.S. §§6301-6386) the Adult Protective Services Act (35 P.S.§§ 10210.101-10210.704) and applicable protective services regulations. | A meeting was held with Director of Human Resources, Director of Operations, Director of Quality Management, Program Specialist, and CEO on 7/1/26 to review the components of this violation. The team discussed the various training options including myODP and Relias. It was determined that Relias does not have all of the training components as required by 6400.51.b.2 therefore, all residential direct service workers will be trained using the myODP Abuse: Detection, Reporting and Prevention of Abuse, Suspected Abuse, and Alleged Abuse training series. https://www.myodp.org/mod/page/view.php?id=24073 |
07/01/2026
| Implemented |
| 6400.52(c)(2) | For the required annual training topic on the prevention, detection and reporting of abuse, suspected abuse, and alleged abuse, Chief Executive Officer #1's annual training for the 2025 calendar year revealed that Chief Executive Officer #1 had only completed the Department's course entitled, "Addressing Day to Day Risks with the Team," on 8/19/2025. However, this session does not incorporate all the required components under the topic on abuse. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | A meeting was held with Director of Human Resources, Director of Operations, Director of Quality Management, Program Specialist, and CEO on 7/1/26 to review the components of this violation. The team discussed the various training options including myODP and Relias. It was determined that Relias does not have all of the training components as required by 6400.51.c.2 therefore, all residential direct service workers will be trained using the myODP Abuse: Detection, Reporting and Prevention of Abuse, Suspected Abuse, and Alleged Abuse training series. https://www.myodp.org/mod/page/view.php?id=24073 |
07/01/2026
| Implemented |
| 6400.166(a)(6) | At 2:47 PM on 6/18/2026, Individual #1's June 2026 Medication Administration Record and medication label reflected a different medication dosage form than what was indicated on the physician orders, dated 5/15/2025, for the prescribed, Vitamin C 1000 MG Powder that read, "Vitamin C Powder 1000 MG---Mix ½ teaspoon in one cup of water (orally) (Supplement Immune System)." However, Individual #1's June 2026 Medication Administration Record documented, "Vitamin C Tablets 1000 MG---Give tablet 1x a day by mouth with water powder (Supplement Immune System)," and the label on the corresponding medication present at the home indicated a 180-count bottle of Vitamin C 1000 MG tablets. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | Individual #1 had an appointment with his PCP on 7/1/2026. During the visit, Program Specialist ensured that Individual #1s PCP updated the medication orders. The Vitamin C is no longer on the medication list, due to a change in which the Vitamin C is only being obtained from a different supplement, as per PCP direction. Individual #1s MAR was updated to reflect the changes in medication. |
07/01/2026
| Implemented |
| 6400.182(c) | Individual #1's Service Plan, last updated 6/3/2026, and their current assessment, completed on 5/28/2026, contained discrepancies in the following health and safety skills domains: regarding poisonous materials, Individual #1's Service Plan, last updated 6/3/2026, stated that, "[Individual #1] does not approach poisonous substances and is able to use dish detergent safely." However, Individual #1's assessment, completed on 5/28/2026, indicated that Individual #1 requires verbal prompting to safely use poisonous substances; regarding fire evacuation, Individual #1's Service Plan, last updated 6/3/2026, informed that Individual #1 requires prompting and physical assistance to respond to the fire alarm while Individual #1's actual fire evacuation ability was unaddressed. In contrast, Individual #1's assessment, completed on 5/28/2026, indicated that Individual #1 requires only verbal prompting to evacuate the home safely in the event of a fire; and regarding community supervision, Individual #1's Service Plan, last updated 6/3/2026, informed that Individual #1 requires 24-hour daily supervision and that they need close monitoring and assistance when crossing streets as well as parking lots, when in communication with others, and when participating in recreational activities out in the community. However, Individual #1's assessment, completed on 5/28/2026, left Individual #1's supervision needs within the community unaddressed entirely. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Individual #1's Individual Assessment was reviewed and updated to reflect the most appropriate information based on residential home assessment.
Program Specialist sent the updated Individual Assessment to Individual #1's Supports Coordinator on 7/3/26. Program Specialist specified requested updates needed to the ISP on the individual assessment form and in the email. This will be documented. |
07/03/2026
| Implemented |