| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Individual #1's assessment, completed on 6/01/2025 states Individual #1 requires full physical assistance to properly use, avoid, and identify poisonous substances. On 10/22/2025 at 10:47 AM, unlocked and accessible in the home's basement on an open shelf were the following poisonous materials: a gallon jug of Eliminator Weed and Grass Killer; and (4) 124 fluid-ounce cans of Valspar Interior Paint and Primer. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Poisonous materials were removed from the home and disposed of on 10/23/25. In the future such poisonous materials will be locked and staff to monitor for continued compliance. |
11/06/2025
| Not Implemented |
| 6400.66 | On 10/22/2025 at 10:24 AM, the exterior lighting fixture outside of the kitchen door leading to the side porch was inoperable, and there was no sufficient, nearby light source. At 10:44 AM, there was no lighting fixture outside of the basement's only exterior door, and there was no sufficient, nearby light source. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Electrician contacted by Provider CEO. Date to be determined but electrician aware of need to replace the fixture. |
12/31/2025
| Implemented |
| 6400.67(a) | On 10/22/2025 at 11:01 AM, the carpet located on the left side of door's threshold leading into the home's vacant bedroom was torn and frayed in a linear area measuring ten inches in length by one and one-half inches wide, revealing the padding underlayment. | Floors, walls, ceilings and other surfaces shall be in good repair. | Carpet will be repaired or replaced as soon as possible but no later than 12/31/25. |
12/31/2025
| Not Implemented |
| 6400.72(a) | On 10/22/2025 at 10:14 AM, the window above the kitchen sink facing the side of the home was fitted with an accordion screen that was smaller than the window frame, leaving a seven-inch gap along the top of the window opening. At 10:32 AM, the window in the dining room, nearest to the kitchen, and facing the right side of the home was fitted with an accordion screen that was smaller than the window frame, leaving an eight-inch gap along the top of the window opening. At 10:35 AM, the window in the living room nearest to the dining room and facing the right side of the home was fitted with an accordion screen that was smaller than the window frame, leaving an eight-inch gap along the top of the window opening. At 10:36 AM, the window in the living room facing the left side of the home did not have a screen. At 10:37 AM, the window in the living room facing the front of the home was fitted with an accordion screen that was smaller than the window frame, leaving a ten-inch gap along the top of the window opening. At 10:53 AM, the window in Individual #1's bedroom facing the front of the home was fitted with an accordion screen that was smaller than the window frame, leaving a one-foot-gap along the top of the window opening. At 10:54 AM, the window in Individual #1's bedroom facing the right side of the home was fitted with an accordion screen that was smaller than the window frame, leaving a ten-inch gap along the top of the window opening. At 10:55 AM, the only window in the bedroom hallway on the home's second floor did not have a screen. At 10:57 AM, the window adjacent to the door of the vacant bedroom located on the home's second floor did not have a screen. At 10:58 AM, the bottom mesh of the screen in the window facing the right side of the home in the vacant bedroom located on the second floor had an oval-shaped tear, measuring one inch by one-half inch in area. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Provider will have contractor install properly fitted screens to all necessary windows/doors. Exact date to be determined by construction company but already aware of need for screens to be replaced. Provider will update as soon as date determined. Estimated mid-December. |
12/31/2025
| Not Implemented |
| 6400.72(b) | On 10/22/2025 at 10:27 AM, the center portion of the glass pane in the bathroom's only window had a circular hole measuring one-eighth of an inch in diameter as well as a cracked area of sprawling fractures measuring approximately one inch in diameter. The surrounding glass around these two damaged areas was intact and flush with the rest of the pane, not posing a safety hazard at this time. | Screens, windows and doors shall be in good repair. | Provider will have contractor install properly fitted screens to all necessary windows/doors. Exact date to be determined by construction company but already aware of need for screens to be replaced. Provider will update as soon as date determined. Estimated mid-December. |
01/31/2026
| Not Implemented |
| 6400.80(b) | On 10/22/2025 at 10:39 AM, there was a loose piece of square glass pane, measuring one foot by one foot in area, with exposed, sharp edges, leaning against the outside of the basement window facing the left side of the home and located at the bottom of the stairs. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | Glass removed next day on !0/23/2025. |
10/23/2025
| Implemented |
| 6400.81(k)(6) | On 10/22/2025 at 11:04 AM, there was no mirror in Individual #1's bedroom. | In bedrooms, each individual shall have the following: A mirror. | Mirror was in top drawer of dresser at time of the inspection. Mirror will remain in her room. |
12/31/2025
| Implemented |
| 6400.101 | On 10/22/2025 at 10:43 AM, in addition to a standard door lock assembly, the interior of the basement's only exterior door was equipped with a sliding chain lock, creating a blocked egress. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| HM removed lock next day 10/23/25. |
12/31/2025
| Implemented |
| 6400.141(c)(3) | Individual #1's current physical examination, completed on 1/23/25, did not address immunizations. It was left blank. | 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. | House Manager obtained individual's immunization record and was placed in her file immediately upon receipt. |
11/01/2025
| Implemented |
| 6400.141(c)(6) | The only tuberculosis test in Individual #1's content of records was documented on Individual #1's current physical examination, completed on 1/23/2025, as a Tuberculin skin test via Mantoux method that was planted on 1/09/2024. "N/A" was marked in the field, entitled "Date read," on this physical examination with additional comments that read, "Reading was completed at Med Express." The agency did not provide documentation from Med Express, indicating the results of the Tuberculin skin test that was planted on 1/09/2024. | 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. | TB testing no longer required every two years by regulations, however, HM to monitor all medical appointment forms for completeness and accuracy during each visit. |
12/31/2025
| Implemented |
| 6400.141(c)(14) | Individual #1's current physical examination, completed on 1/23/25, did not address medical information pertinent to diagnosis and treatment in case of an emergency. It was left blank. [Repeated Violation-10/29/24, et al] | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Physical examination including medical information pertinent to diagnosis will be completed ikn its en tirety and medical information pertinent to diagnosis will be obtained from PCP. HM will monitor at all appointments for medical form completion and accuracy. |
12/31/2025
| Not Implemented |
| 6400.142(a) | Individual #1 had a dental examination completed on 6/27/2024 and not again since. Individual #1 had a dental examination completed on 6/27/2024 which was not dated by the dentist who had completed the examination. [Repeated Violation-10/29/24, et al] | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | HM will ensure via appointment tracker forms that all appointments are completed, and new medical appointment forms will be completed in their entirety and accurately. |
12/31/2025
| Implemented |
| 6400.181(e)(10) | Individual #1's assessment, completed by Program Specialist #2 on 6/01/2025, included a lifetime medical history, however, it did not include a comprehensive medical history for Individual #1; rather, it only listed Individual #1's current medical contacts. | The assessment must include the following information: A lifetime medical history. | Provider has developed a more comprehensive lifetime medical for each individual and PS is working on implementing the newer more comprehensive lifetime medical. |
12/31/2025
| Implemented |
| 6400.181(e)(12) | Individual #1's assessment, completed by Program Specialist #2 6/01/2025, did not include recommendations for specific areas of training, programming, and services. This section of the assessment stated, "Continue 1:1 supports and continue behavioral supports." | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Provider developed and implemented a new assessment and includes a section for recommendations. Program specialist is now aware of requirements for this area of the assessment and the information that needs to be included here. |
12/31/2025
| Not Implemented |
| 6400.214(b) | On 10/22/2025 at 11:30 AM, 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.
| Psychological evaluation was obtained and placed in her home. |
12/31/2025
| Not Implemented |
| 6400.20(b) | The home did not review and analyze incidents and conduct and document a trend analysis at least every 3 months. | The home shall review and analyze incidents and conduct and document a trend analysis at least every 3 months. | Trend analysis completed for first three quarters of 2025. CEO will monitor quarterly to esnure regulatory compliance is maintained. |
12/31/2025
| Not Implemented |
| 6400.32(r)(5) | On 10/22/2025 at 11:04 AM, Individual #1's bedroom door was equipped with lock, requiring a key to disengage it from the outside. In an interview conducted with Chief Executive Officer #1, it was revealed that staff did not possess a key to operate the lock on Individual #1's bedroom door. | Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door. | Maintenance to replace doorknob as soon as possible with knob equipped with locking mechanism and key. Staff will educate individual how to lock and unlock her door. House managers will be conducting a monthly home inspection which will include ensuring doorknob works properly and that individual may lock and unlock her door. |
12/31/2025
| Implemented |
| 6400.182(c) | Individual #1's Individual Support Plan, last updated 8/25/2025, contained the following discrepancies between their current assessment, completed on 6/01/2025, in the following health and safety skill domains: regarding poisonous materials, Individual #1's Individual Support Plan, last updated 8/25/2025, stated that "All chemicals···are locked for [their] safety." The plan contained no reference to or language regarding Individual #1's ability to use or avoid poisonous materials. Individual #1's assessment, completed on 6/01/2025, stated that Individual #1 requires full physical assistance to properly use, avoid, and identify poisonous substances; regarding non-insulated heat sources exceeding 120 degrees Fahrenheit, Individual #1's Individual Support Plan, last updated 8/25/2025, stated that Individual #1 must be "visually monitored around all heat sources." Individual #1's assessment, completed on 6/01/2025, stated that Individual #1 requires no support for understanding the danger of heat sources; regarding fire evacuation, Individual #1's Individual Support Plan, last updated 8/25/2025, stated that "[Individual #1] needs verbal assistance evacuating safely within 2.5 minutes in the event of a fire." Individual #1's assessment, completed on 6/01/2025, stated that Individual #1 needs no support to evacuate within 2.5 minutes in the event of a fire; and regarding supervision within the home, Individual #1's Individual Support Plan, last updated 8/25/2025, states Individual #1 requires 24-hour supervision and that Individual #1 needs to be "within hearing distance/ line of sight [of] [staff ] at all times for [their] safety," and that "[Individual #1] can become aggressive and needs support and redirection." Individual #1's assessment, completed on 6/01/2025, states Individual #1 requires a 1:1 staffing ratio within the home and states Individual #1 can use the restroom independently. [Repeated Violation-10/29/24, et al] | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Program specialist will complete a new assessment updating and displaying current information/abilities of the individual. Once assessment completed PS to send to SC and ensure necessary changes are made in the ISP. |
12/31/2025
| Not Implemented |
| 6400.186 | Individual #1's restrictive procedure plan, dated 5/30/2025, stated that "Due to physical/ verbal aggression, all sharp objects, including forks and knives, are locked for [Individual #1's] safety. On 10/22/2025 at 10:18 AM there were several metal forks located in the top silverware drawer situated to the right of the kitchen sink. | The home shall implement the individual plan, including revisions. | Forks were placed in locked area of the kitchen with other sharps. |
10/23/2025
| Implemented |
| 6400.195(b) | Individual #1 has a restrictive procedure plan implemented by the agency for access limitations on sharp objects, including knives and forks. This restrictive procedure plan was reviewed and approved by the human rights team on 9/11/2024, and then again on 5/30/2025. | The behavior support component of the individual plan shall be reviewed and revised as necessary by the human rights team, according to the time frame established by the team, not to exceed 6 months between reviews. | Plan was reviewed on 11/5/2025 by the HRT. HRT committee will meet at least quarterly and update plans at least every six months for continued compliance. |
11/05/2025
| Implemented |