| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | There was dirt and grime built up in the first-floor window and screen tracks. | Clean and sanitary conditions shall be maintained in the home. | Immediately following the inspection, the Program Director and Direct Support Professionals thoroughly cleaned the first-floor window and screen tracks to remove the dirt and grime that had accumulated. The window frame, sill, and surrounding surfaces were cleaned and sanitized to restore sanitary conditions.
Following the cleaning, the Program Director inspected the window and surrounding areas to ensure the condition had been corrected and Other windows throughout the home to ensure that similar sanitation concerns were not present. |
02/11/2026
| Implemented |
| 6400.65 | The second-floor bathroom did not have a window nor mechanical ventilation. There was a skylight that could not be opened. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Maintenance personnel were contacted to evaluate the bathroom ventilation. The window/skylight was opened to ensure the bathroom has proper ventilation in accordance with §6400.65. |
02/13/2026
| Implemented |
| 6400.66 | The light outside of the backdoor did not turn on. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Work order was submitted and maintenance replaced the exterior light bulb located outside of the back door. After replacement, the House Manager confirmed that the exterior light was functioning properly and providing adequate illumination for the doorway and steps leading from the home.
The House Manager also reviewed lighting fixtures throughout the residence to ensure that interior and exterior lighting was functioning properly. |
02/13/2026
| Implemented |
| 6400.82(f) | The second-floor bathroom had no garbage can or paper or cloth towels. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Immediately following the inspection, the Direct Support Professional on duty placed a trash receptacle and paper towels in the second-floor bathroom to ensure that all required items were available for use. The Program Director confirmed that the bathroom contained the required items including soap, toilet paper, towels, mirror, sink, and trash receptacle.
The PD also inspected all bathrooms within the home to verify that each bathroom was equipped with the required supplies. The Program Specialist verified the correction during follow-up review. |
02/11/2026
| Implemented |
| 6400.101 | Individual #4's bedroom door only opened about half of the way due to being blocked by the individual's desk and equipment. During the inspection the desk and equipment were moved to allow the door to open all of the way. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| During the inspection, the desk and equipment blocking Individual #4's bedroom doorway were immediately moved to allow the bedroom door to open fully and ensure the doorway and exit path were unobstructed. Following the inspection, the Program Director reviewed the bedroom layout with Individual #4 to ensure that furniture and equipment were arranged in a manner that does not block access to doorways or exits. |
02/11/2026
| Implemented |
| 6400.105 | The indoor dryer lint catcher was not effective with catching the lint as there was lint behind and to the side of the dryer. | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| Immediately following the inspection, Direct Support Staff removed the lint buildup located behind and beside the dryer and thoroughly cleaned the lint trap to ensure the dryer was functioning safely. The surrounding laundry area was cleaned to remove all lint and other combustible materials. Maintenance order was submitted for the purchase install of a new lint trap for indoor dryer vents.
Maintenance was notified regarding the exposed wire hanging from the ceiling near the light bulb. The wire was secured and repositioned away from the heat source to eliminate the potential fire hazard.
Following these corrections, the House Manager inspected the laundry area and other utility spaces in the home to ensure that flammable or combustible materials were not located near heat sources and that equipment was being used safely. |
03/25/2026
| Implemented |
| 6400.112(a) | There was no fire drill held with individual #5 present in the household from 11/2025 through 01/2026. | An unannounced fire drill shall be held at least once a month. | Due to individual elopement for long periods of time in the home, he was not present during the fire drills completed during that timeframe. An unannounced fire drill was conducted in the home with Individual #5 present to ensure the individual participated in the evacuation procedure.
The Program Specialist reviewed all fire drill documentation for the previous year to determine whether any additional months were missing documentation or participation by individuals residing in the home. Staff responsible for conducting fire drills were re-educated on the regulatory requirement that an unannounced fire drill must be conducted at least monthly and that all individuals residing in the home should participate whenever they are present in the residence.
Individual was also educated on the importance of being present and participate in fire drills |
02/16/2026
| Implemented |
| 6400.112(c) | There was no evacuation time for the 04/06/25 fire drill. | 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 responsible for conducting fire drills were re-educated on the required fire drill documentation elements under §6400.112(c), including recording the evacuation time in minutes and seconds.
The Program Specialist also conducted a review of all fire drill documentation maintained in the home to determine whether any additional records were incomplete. Any identified documentation issues were corrected where possible and staff were provided guidance to ensure accurate completion of fire drill records. This corrective action was completed on 2/13/2026. |
02/13/2026
| Implemented |
| 6400.151(c)(2) | Staff Person #2's physical completed on 11/20/24 does not include TB test results. | 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. | Following the inspection, the Human Resources Coordinator reviewed the personnel record for Staff Person #2 and confirmed that the TB test results were not included with the physical examination documentation dated 11/20/2024. Staff Person #2 was immediately scheduled to obtain a TB test through a qualified medical provider. |
03/27/2026
| Implemented |
| 6400.52(a)(1) | Staff Person #2 did not complete 24 hours of training during the training year spanning 1/1/2025-12/31/2025 | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | : The training Specialist reviewed the training records for all staff to verify compliance with annual training requirements. Staff Person #2 was scheduled to complete the remaining training hours required to meet the regulatory requirement. The correction will be completed by March 27th, 2026. |
03/27/2026
| Implemented |
| 6400.166(a)(2) | The MAR for individual #4 did not include the names of the prescribers. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | Following the inspection, the Program Specialist and agency nurse reviewed the Medication Administration Record (MAR) for Individual #4 and confirmed that the prescribers' names were not documented. The nurse verified the prescribing physicians for each medication through the pharmacy and physician orders and updated the MAR to include the name of the prescriber for each medication.
The Program Specialist and nurse conducted a review of all MARs maintained in the home to determine whether prescriber names were documented for each medication administered to individuals residing in the home. Any missing prescriber information identified during the review was corrected to ensure medication records were complete |
03/06/2026
| Implemented |
| 6400.166(a)(7) | The medication label of the Multivitamin states that it is a generic for Centrum Silver, but it does not have a dosage on it. The MAR gives a dosage of the multivitamin minerals states strength 7.5 mg iron 400 mcg for Individual #4. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | Following the inspection, the Program Specialist and agency nurse reviewed the medication packaging and the Medication Administration Record (MAR) for Individual #4. The nurse contacted the pharmacy to verify the correct dosage information for the multivitamin medication and confirmed the appropriate dosage and strength with the prescribing physician and pharmacy label. The MAR was updated to reflect the correct medication dosage consistent with the physician's order and pharmacy information.
The Program Specialist and agency nurse also reviewed medication records and medication labels for all individuals residing in the home to determine whether dosage information was clearly documented on each MAR and consistent with pharmacy labels and physician orders. |
02/16/2026
| Implemented |
| 6400.166(a)(11) | The MAR for individual #4 did not include the diagnosis or purpose for the medication Famotidine. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Following the inspection, the Program Specialist and agency nurse reviewed the medication packaging and MAR documentation for the multivitamin administered to Individual #4. The nurse verified the correct dosage with the pharmacy and prescribing physician. The MAR was updated to reflect the correct medication dosage and documentation consistent with the pharmacy label and physician order.
The Program Specialist and nurse also reviewed medication records for all individuals residing in the home to ensure that dosage information was documented accurately on each MAR. |
02/16/2026
| Implemented |
| 6400.166(c) | Individual #4 refused the medication Fluticasone on 02/03/26, 02/04/26, 02/09/26, 02/10/26, and 02/11/26 which was documented on the MAR, but no evidence was provided that the refusals were reported to the prescriber. | If an individual refuses to take a prescribed medication, the refusal shall be documented on the medication record. The refusal shall be reported to the prescriber as directed by the prescriber or if there is harm to the individual. | Following the inspection, the Program Specialist and agency nurse reviewed the MAR documentation regarding the medication refusals for Individual #4. The prescribing doctor did not want to be notified of refusals for this individual.
Staff responsible for medication administration were re-educated by the agency nurse regarding medication refusal procedures, including documentation on the MAR and timely notification of the prescribing physician in accordance with physician orders and agency policy. |
02/16/2026
| Implemented |