| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(a) | The home does not have hot water under pressure in the bathtub of the home. Water temperature in the bathtub only measured 83 degrees. Hot water in the sink of the home measured 117.5 degrees. | A home shall have hot and cold running water under pressure. | Corrective action was completed the same day the issue was identified. Repairs were immediately completed by the maintenance department to restore hot water under pressure to the bathtub. Following the repair, water temperature and pressure were tested to confirm proper hot and cold running water under pressure was available. |
01/05/2026
| Implemented |
| 6400.181(a) | Individual #1 did not have an assessment completed annually. Individual #1 has an assessment completed on 3/17/23 and did not have another completed until 6/24/25. | 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. | Upon identification that Individual #1 did not receive an updated annual assessment within the required timeframe, corrective action was taken. An updated assessment was completed on 6/24/25, and a subsequent comprehensive and current assessment was completed on 2/6/26 to accurately reflect Individual #1's current needs, skills, and adaptive functioning. The most current assessment dated 2/6/26 is the assessment being used to guide services and planning and has been placed in the individual's record as well as sent to the ISP Team. |
02/06/2026
| Implemented |
| 6400.181(e)(13)(i) | Individual #1's annual assessment dated 6/24/25 does not include the individual's progress over the last 365 calendar days in the area of health. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| Upon identification that Individual #1's annual assessment dated 6/24/25 did not include documentation of the individual's progress over the previous 365 calendar days in the area of health, corrective action was taken. Individual #1's assessment and Individual Service Plan (ISP) were reviewed in full. A corrected, current assessment specific to Individual #1 was completed to accurately reflect the individual's needs, abilities, supervision requirements, skill levels, and supports, including documentation of the individual's progress over the last 365 calendar days and current level of functioning in the area of health. |
02/06/2026
| Implemented |
| 6400.181(e)(13)(ii) | Individual #1's annual assessment dated 6/24/25 does not include the individual's progress over the last 365 calendar days in the area of motor and communication skills. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | Upon identification that Individual #1's annual assessment dated 6/24/25 did not include documentation of the individual's progress over the previous 365 calendar days in the area of motor and communication skills, corrective action was taken. Individual #1's assessment and Individual Service Plan (ISP) were reviewed in full. A corrected, current assessment specific to Individual #1 was completed to accurately reflect the individual's needs, abilities, supervision requirements, skill levels, and supports, including documentation of the individual's progress over the last 365 calendar days and current level of functioning in the area of motor and communication skills. |
02/06/2026
| Implemented |
| 6400.181(e)(13)(iii) | Individual #1's annual assessment dated 6/24/25 does not include the individual's progress over the last 365 calendar days in the area of activities of residential living. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | Upon identification that Individual #1's annual assessment dated 6/24/25 did not include documentation of the individual's progress over the previous 365 calendar days in the area of activities of residential living, corrective action was taken. Individual #1's assessment and Individual Service Plan (ISP) were reviewed in full. A corrected, current assessment specific to Individual #1 was completed to accurately reflect the individual's needs, abilities, supervision requirements, skill levels, and supports, including documentation of the individual's progress over the last 365 calendar days and current level of functioning in the area of activities of residential living. |
02/06/2026
| Implemented |
| 6400.181(e)(13)(iv) | Individual #1's annual assessment dated 6/24/25 does not include the individual's progress over the last 365 calendar days in the area of personal adjustment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | Upon identification that Individual #1's annual assessment dated 6/24/25 did not include documentation of the individual's progress over the previous 365 calendar days in the area of personal adjustment, corrective action was taken. Individual #1's assessment and Individual Service Plan (ISP) were reviewed in full. A corrected, current assessment specific to Individual #1 was completed to accurately reflect the individual's needs, abilities, supervision requirements, skill levels, and supports, including documentation of the individual's progress over the last 365 calendar days and current level of functioning in the area of personal adjustment. |
02/06/2026
| Implemented |
| 6400.181(e)(13)(v) | Individual #1's annual assessment dated 6/24/25 does not include the individual's progress over the last 365 calendar days in the area of socialization. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | Upon identification that Individual #1's annual assessment dated 6/24/25 did not include documentation of the individual's progress over the previous 365 calendar days in the area of socialization, corrective action was taken. Individual #1's assessment and Individual Service Plan (ISP) were reviewed in full. A corrected, current assessment specific to Individual #1 was completed to accurately reflect the individual's needs, abilities, supervision requirements, skill levels, and supports, including documentation of the individual's progress over the last 365 calendar days and current level of functioning in the area of socialization. |
02/06/2026
| Implemented |
| 6400.181(e)(13)(vi) | Individual #1's annual assessment dated 6/24/25 does not include the individual's progress over the last 365 calendar days in the area of recreation. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | Upon identification that Individual #1's annual assessment dated 6/24/25 did not include documentation of the individual's progress over the previous 365 calendar days in the area of recreation, corrective action was taken. Individual #1's assessment and Individual Service Plan (ISP) were reviewed in full. A corrected, current assessment specific to Individual #1 was completed to accurately reflect the individual's needs, abilities, supervision requirements, skill levels, and supports, including documentation of the individual's progress over the last 365 calendar days and current level of functioning in the area of recreation. |
02/06/2026
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's annual assessment dated 6/24/25 does not include the individual's progress over the last 365 calendar days in the area of financial independence. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| Upon identification that Individual #1's annual assessment dated 6/24/25 did not include documentation of the individual's progress over the previous 365 calendar days in the area of financial independence, corrective action was taken. Individual #1's assessment and Individual Service Plan (ISP) were reviewed in full. A corrected, current assessment specific to Individual #1 was completed to accurately reflect the individual's needs, abilities, supervision requirements, skill levels, and supports, including documentation of the individual's progress over the last 365 calendar days and current level of functioning in the area of financial independence. |
02/06/2026
| Implemented |
| 6400.181(e)(13)(viii) | Individual #1's annual assessment dated 6/24/25 does not include the individual's progress over the last 365 calendar days in the area of managing personal property. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | Upon identification that Individual #1's annual assessment dated 6/24/25 did not include documentation of the individual's progress over the previous 365 calendar days in the area of managing personal property, corrective action was taken. Individual #1's assessment and Individual Service Plan (ISP) were reviewed in full. A corrected, current assessment specific to Individual #1 was completed to accurately reflect the individual's needs, abilities, supervision requirements, skill levels, and supports, including documentation of the individual's progress over the last 365 calendar days and current level of functioning in the area of managing personal property. |
02/06/2026
| Implemented |
| 6400.181(e)(13)(ix) | Individual #1's annual assessment dated 6/24/25 does not include the individual's progress over the last 365 calendar days in the area of community integration. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration. | Upon identification that Individual #1's annual assessment dated 6/24/25 did not include documentation of the individual's progress over the previous 365 calendar days in the area of community integration, corrective action was taken. Individual #1's assessment and Individual Service Plan (ISP) were reviewed in full. A corrected, current assessment specific to Individual #1 was completed to accurately reflect the individual's needs, abilities, supervision requirements, skill levels, and supports, including documentation of the individual's progress over the last 365 calendar days and current level of functioning in the area of community integration. |
02/06/2026
| Implemented |
| 6400.44(c)(2) | Staff #2 is the program specialist. Staff #2 does not meet the qualifications as program specialist. Staff #2 has a bachelor's degree but does not have two years of experience working with individuals with autism or intellectual disabilities. | A program specialist shall have one of the following groups of qualifications: A bachelor's degree from an accredited college or university and 2 years of work experience working directly with individuals with an intellectual disability or autism. | Upon identification that Staff #2 did not meet the required qualifications to serve as Program Specialist, corrective action was taken. Staff #2 was removed from Program Specialist duties. The provider ensured that Program Specialist responsibilities are assigned only to individuals who meet the regulatory qualifications in the interim. The provider reviewed staffing assignments to ensure compliance with qualification requirements and documented the corrective action taken. |
01/08/2026
| Implemented |
| 6400.165(g) | Individual #2 is prescribed medication to treat symptoms of psychiatric illness. Individual #1 had reviews of this medication on 3/1/25, 5/6/25, 5/20/25, 6/17/25, and 8/19/25. These medication reviews did not include the necessary dosage of the medications in Individual #1 is prescribed. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Corrective action included immediate conversations with all treating psychiatrists regarding documentation requirements. Individual #1's medication review records were updated to include the diagnosis being treated, the reason for prescribing the medication, the need for continued use, and the prescribed dosage, in accordance with regulatory requirements. The individual's record was reviewed to ensure documentation is complete and current. |
01/12/2026
| Implemented |
| 6400.181(f) | Individual #1's assessment dated 6/24/25 was not sent to Individual #1's team at least 30 days prior to Individual #1's Individual Service Plan meeting that was held on 6/25/25. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Upon identification that Individual #1's assessment dated 6/24/25 was not provided to the individual plan team at least 30 days prior to the Individual Service Plan meeting held on 6/25/25, corrective action was taken. Procedures were reviewed with the program specialist to ensure assessments are completed and distributed within required timeframes. The assessment process was reviewed to prevent recurrence. |
02/06/2026
| Implemented |
| 6400.182(c) | 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 plan is not developed based upon a current assessment. Individual #1's assessment dated 6/24/25 contains multiple areas of information that is not consistent with the information contained in Individual #1's Individual Service Plan dated 6/27/25 and last updated 8/6/25. Areas of inconsistency include supervision, financial management, the individual's ability to care for personal hygiene needs, home care, self-medicating, ability to use a computer, internet, financial management skills, bathing skills, home management skills, First aid/emergency response skills, personal interactions, recreation, and personal adjustment. Individual #1's assessment refers to Individual #1 as she and her in multiple areas. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Upon identification that Individual #1's Individual Service Plan (ISP) was not developed based upon a current and accurate assessment, immediate corrective action was taken. Individual #1's assessment and ISP were reviewed in full. A corrected, current assessment specific to Individual #1 was completed to accurately reflect the individual's needs, abilities, supervision requirements, skill levels, and supports, including but not limited to personal hygiene, home management, financial management, medication administration, use of technology, personal interactions, recreation, and emergency response skills. The corrected assessment has been forwarded over to the team so that, Individual #1's ISP can be revised if necessary to ensure consistency with the assessment and to accurately reflect the individual's current needs and services. Documentation of the updated assessment has been placed in the individual's record. |
02/06/2026
| Implemented |
| 6400.213(1)(i) | Individual #1's record does not include the individuals' religion. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Upon identification that Individual #1's record did not include the individual's religion, corrective action was taken. Individual #1's face sheet was revised to include the individual's religion. The record was reviewed to ensure all required personal information is complete. |
02/06/2026
| Implemented |