| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(e) | There were no fire drills held during sleeping hours from 7/2024 through 5/2025. | A fire drill shall be held during sleeping hours at least every 6 months. | The provider will immediately schedule and conduct a fire drill during sleeping hours between the hours of 2am-4am to comply with the six-month requirement of conducting a fire drill within sleeping hours. |
06/10/2025
| Implemented |
| 6400.214(b) | On 6/4/2025 at 11:25AM, the most recent copy of Individual #1's Service Plan was not present at the home. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| Individual #1's most recent copy of service plan will be taken to the house to replace the existing service plan immediately. |
06/10/2025
| Implemented |
| 6400.32(r)(1) | On 6/4/2025 at 10:19AM, there was a turn locking mechanism on the inside and a thumbnail locking mechanism on the outside of Individual #1's bedroom door. Individual #1 has not been provided with a designated mechanism to lock and unlock the door independently. | 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. | On 6/10/2025, Individual #1 was reviewed and counseled regarding bedroom door locks. It was determined that this individual does not require a locking bedroom door. The doorknob was changed to a bedroom doorknob that does not have a locking device. Individual #1 signed a consent acknowledging that no door lock is necessary at this time. Documentation of the correction was completed and placed in the individual¿s record. |
06/10/2025
| Implemented |
| 6400.50(a) | The records of annual training year, 1/1/2024 through 12/31/2024, for Chief Executive Officer/Program Specialist #1 did not include the training content. The records of orientation for Direct Service Worker #3, date of hire 8/12/2024, did not include the training content. | 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. | Direct Service Worker #1's file will be reviewed by the HR manager and missing content details, to include a training syllabus, will be added. This will include specifying the training topic, source, content summary, date(s), length of trainings, and certificates (if applicable). |
06/13/2025
| Implemented |
| 6400.51(b)(5) | Direct Service Worker #3, date of hire 8/12/2024, was not trained on the service plans of the individuals residing in the home. | The orientation must encompass the following areas: Job-related knowledge and skills. | Direct Service Worker #3 will complete Implementation of the Individual Plan by 6/14/2025. The Training Coordinator will complete the training in person and discuss the Support Plan for each individual that resides in the home. Key components will focus on person centered practices, likes and dislikes, effective communication with the individuals we serve, health and safety and desired outcomes.
Training for Direct Service Worker #3 related to Implementation of the Service Plan was completed during annual training year 2024 however, proper documentation was not maintained in the employee file. |
06/27/2025
| Implemented |
| 6400.52(c)(5) | Chief Executive Officer/Program Specialist #1, date of hire 4/22/2021, was not trained on the safe and appropriate use of behavior supports during the annual training year 1/1/2024 through 12/31/2024. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | CEO/Program Specialist #1 will be retrained on the safe and appropriate use of behavior supports by 6/14/2025. This will be on-site training that is conducted by the training coordinator. Content will include support plans specific to individuals present in the home. Behavior interventions and specific behavior support plans, when applicable, will be reviewed. Positive reinforcement, crisis intervention, and functional behavior assessments will be reviewed.
Annual training for CEO/Program Specialist #1 was completed during annual training year 2024 however, proper documentation was not maintained in the employee file. |
06/27/2025
| Implemented |
| 6400.52(c)(6) | Chief Executive Officer/Program Specialist #1, date of hire 4/22/2021, was not trained on the implementation of the individual plans during the annual training year 1/1/2024 through 12/31/2024. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | CEO/Program Specialist #1 will complete Implementation of the Individual Plan by 6/14/2025. The Training Coordinator will complete the training in person and discuss the Support Plan for each individual that resides in the home. Key components will focus on person centered practices, likes and dislikes, effective communication with the individuals we serve, health and safety and desired outcomes.
Annual training for CEO/Program Specialist #1 was completed during annual training year 2024 however, proper documentation was not maintained in the employee file. |
06/27/2025
| Implemented |
| 6400.166(a)(13) | Direct Service Worker #2 administered medications to Individual #1 on 6/1/2025. Individual #1's June 2025 Medication Administration Record did not include the name of Direct Service Worker #2. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. The medication administration trainer will make contact with Direct Service Worker #2 prior to the start of her next shift to retrain her related to signatures and initials on the MAR at the beginning of each month, prior to administering medications. The trainer will ensure Direct Service Worker #2 signs and initials the MAR. |
06/07/2025
| Implemented |
| 6400.169(d) | Chief Executive Officer/Program Specialist #1 completed Medication Administration Training on 10/2/2024. This training was facilitated by a trainer that is employed outside of this provider agency. The provider agency did not provide verification of the trainer's Medication Administration Trainer Certification or the contract with the provider agency with whom the trainer is employed. | A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed. | Prior to administering medication to any individual, the CEO/Program Specialist #1 will complete the medication administration course again to ensure certification is up to date and in compliance with 6400 regulations. Please note that the CEO/Program Specialist #1 has not administered medication to any individual within the past 12 months. |
06/10/2025
| Implemented |