| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(e)(1) | Individual #1's Service Plan, last updated 6/19/25, states that "[Individual #1 is not able to manage [their] funds." "It is important that [Individual #1] has support to assist [them] in managing [their] finances." On 7/23/25, Individual #1's financial ledger had last been updated with a transaction entered on 6/2/25. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. | The individual has been set up with a bank account so that he is able to utilize a debit card. However, when he has cash, a financial ledger will be used for the staff to assist the individual to manage their finances. The ledger includes dates and amounts of deposits and withdrawals to account for his finances at hand. |
09/01/2025
| Implemented |
| 6400.62(a) | Individual #1's initial assessment, completed on 2/14/25, indicated "No," regarding their ability to safely use or avoid poisonous materials and added, "[Individual #1] requires supervision when using household cleaning products." The two doors to the staff office were equipped with privacy door locks, both having thumbnail, straight-edge access points on the entry side and turn latches on the inside. The closet door in the staff office was also equipped with a privacy door lock having a thumbnail, straight-edge access point on the inside and a turn latch on the entry side. At 12:00 PM on 7/23/25, all three of these doors were unlocked and the following poisonous materials were found accessible in the closet: two 10-fluid ounce bottles of Gain Laundry Detergent. | Poisonous materials shall be kept locked or made inaccessible to individuals. | All poisonous materials have been safely locked in the closet of the staff office. Team Lead, Program Specialist and all staff were trained where the poisonous materials will be kept and should remain when not in use. |
09/01/2025
| Implemented |
| 6400.64(f) | At 10:16 AM on 7/23/25, there was an open, torn white garbage bag hanging off the back deck railing containing paper plates, several empty plastic water bottles, an empty aluminum Brisk Iced Tea can, and other refuse. At 10:15 AM on 7/23/25, laying on the ground underneath the rear deck were several candy wrappers, empty plastic water bottles, empty plastic soda bottles, plastic utensils, a plastic measuring cup, empty chip bags, an empty toilet paper roll, a medical appointment card, an empty cardboard box, and other refuse. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | The area in question has been cleaned (ground underneath the rear deck). |
09/01/2025
| Implemented |
| 6400.67(b) | At 10:16 AM on 7/23/25, the paint in several areas throughout the interior side of the storm door attached to the kitchen door leading out to the rear deck was missing, chipped, and flaking, thus, exposing sharp edges of the finish itself. [Repeated Violation-7/30/24 et al.] | Floors, walls, ceilings and other surfaces shall be free of hazards. | A new storm door has been ordered. A picture will be sent to the Department with the POC. |
09/01/2025
| Implemented |
| 6400.71 | At 10:36 AM on 7/23/25, emergency phone numbers of the nearest hospital, police department, fire department, ambulance, and poison control center were not posted on or nearby the telephone situated on the television stand located in the living room on the home's main level. [Repeated Violation-7/30/24 et al.] | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| Telephone numbers of the nearest hospital, police department, fire department, ambulance, and poison control center were placed by each telephone in the home with an outside line. A picture will be sent to the Department along with the POC. |
08/25/2025
| Implemented |
| 6400.72(a) | At 10:48 AM on 7/23/25, the window in the staff office facing the front of the home did not have a screen. At 11:15 AM, the window facing the side of the home in the vacant bedroom located on the third floor did not have a screen. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | The vacant bedroom on the third floor had a screen put in. A picture of screen will be sent to the Department along with the POC. |
09/01/2025
| Implemented |
| 6400.72(b) | At 10:38 AM on 7/23/25, the screen in the left window of the living room facing the side of the home contained two circular tears in its center, each measuring approximately one-fourth inch in diameter. At 10:48 AM, the screen in the window of the staff office facing the side of the home had a circular tear in its center, measuring approximately one-fourth in diameter. At 11:15 AM, the center of the screen in the window of the vacant bedroom on the third floor facing the back of the home was torn in an area, measuring approximately two inches by one inch. | Screens, windows and doors shall be in good repair. | The window screens in question (left window of the living room, screen in the window of the staff office facing the side of the home, vacant bedroom window) were replaced with new screens. Pictures of the screens will be sent to the Department. |
09/01/2025
| Implemented |
| 6400.77(b) | At 10:47 AM on 7/23/25, the home's first aid kit did not contain a thermometer. [Repeated Violation-7/30/24 et al.] | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | Thermometer was replaced, and the first aid kit is now complete. A picture of the thermometer will be sent to the Department. |
09/01/2025
| Implemented |
| 6400.101 | At 11:25 AM on 7/23/25, the interior basement door leading to the attached garage was equipped with a sliding latch lock and a retractable security bar facing the basement side. There is no exterior swing door from the attached garage to prevent entrapment. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The sliding latch lock and retractable security bar facing the basement side were removed. A picture of the interior basement door will be sent to the Department. |
09/01/2025
| Implemented |
| 6400.105 | At 11:26 AM on 7/23/25, the gas hot water tank, located in the home's basement, was seated upon a piece of combustible Luan wood. [Repeated Violation-7/30/24 et al.] | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| The piece of Luan wood was removed, and the water tank is no longer sitting on it. A picture of the water tank with the removed Luan wood will be sent to the Department. |
09/01/2025
| Implemented |
| 6400.113(a) | Individual #1's date-of-admission is 12/17/24. Their initial fire safety training, completed on 12/17/24 did not address the following required content relative to their place of residence: 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. [Repeated Violation-7/30/24 et al.] | 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. | The individual completed an updated fire safety training that includes content related to their place of residence: 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 procedures if the individuals smoke at home.
The updated fire training safety signed by the individual will be sent the Department. |
09/01/2025
| Implemented |
| 6400.181(e)(10) | Individual #1's date-of-admission is 12/17/24. Their initial and current assessment, completed on 2/14/25, did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | A lifetime medical history was developed for the individual.
TM's developed lifetime medical history will be sent to the Department. |
09/08/2025
| Implemented |
| 6400.181(e)(11) | Individual #1's date-of-admission is 12/17/24. Their initial and current assessment, completed on 2/14/25, did not include an applicable psychological evaluation. | The assessment must include the following information: Psychological evaluations, if applicable. | In the future, the Program Specialist will submit an assessment cover page to the individual¿s Support Coordinator and treatment team, which includes the following:
o Lifetime Medical History
o Yearly Doctor Appointments
o Psychological Evaluation
o Current List of Medications
A copy of the Assessment Cover Page Checklist will be sent to the Department. |
09/08/2025
| Implemented |
| 6400.216(a) | The two doors to the staff office were equipped with privacy door locks, both having thumbnail, straight-edge access points on the entry side and turn latches on the inside. The closet door in the staff office was also equipped with a privacy door lock having a thumbnail, straight-edge access point on the inside and a turn latch on the entry side. At 10:48 AM on 7/23/25, all three of these doors were unlocked. Inside the closet was a white binder, entitled, "[Agency #2]: ["Individual #1]---Program Book," containing demographic information, a birth certificate, medical insurance information, Individual Service Plans, a Room and Board Contract, and other personal information. | An individual's records shall be kept locked when unattended.
| The individual¿s record has been locked. A picture of the locked doors and staff training sign in sheet will be sent to the Department. |
09/01/2025
| Implemented |
| 6400.32(d) | At 10:38 AM on 7/23/25, posted in plain view on the wall in the living room was a sign ithat read "Stop! No food beyond this point!" | An individual shall be treated with dignity and respect. | Sign was taken off the wall in the living room. A picture of the wall evidencing that the sign was taken down will be sent to the Department. |
09/01/2025
| Implemented |
| 6400.32(r)(1) | At 11:10 AM on 7/23/25, the privacy door lock to Individual #1's bedroom was equipped with a turn latch on the inside and a pinhole access point on the entry side. This bedroom door locking system does not provide Individual #1 with a unique mechanism or entry device to lock and unlock their bedroom door. | 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. | The doorknob has been changed to a knob that is equipped with a door locking system to use a key to lock or unlock their bedroom door. The individual has chosen to lock their door using a key. A spare key will be accessible to staff for emergency purposes. |
09/01/2025
| Implemented |
| 6400.32(r)(4) | At 11:10 AM on 7/23/25, the privacy door lock to Individual #1's bedroom was equipped with a turn latch on the inside and a pinhole access point on the entry side. This bedroom door locking system does not allow easy and immediate access by the individual and staff persons in the event of an emergency. | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. | The doorknob has been changed to a knob that is equipped with a door locking system to use a key to lock or unlock their bedroom door. A spare key will be accessible to staff for emergency purposes. |
09/01/2025
| Implemented |
| 6400.51(b)(5) | Direct Service Provider #1's date-of-hire is 3/24/25. Their orientation training did not include completion of job-related knowledge and skills regarding individual-specific reviews of behavior support plans. | The orientation must encompass the following areas: Job-related knowledge and skills. | The staff in question completed individual specific training on BSP. |
09/01/2025
| Implemented |
| 6400.163(d) | At 10:47 AM on 7/23/25, the home's first aid kit had the following unlocked, accessible over-the-counter medications: three packets of Aspirin, each containing two 325 MG tablets. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | The first aid kit was locked, and the key was placed in a designated area of the office. |
09/01/2025
| Implemented |
| 6400.163(h) | At 10:47 AM on 7/23/25, the home's first aid kit contained the following expired over-the-counter medications: three packets of Aspirin, each containing two 325 MG tablets, and each with an expiration date of 2-2025. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | The home¿s first aid kit, containing the expired over-the-counter packets of Aspirin, was discarded. |
09/01/2025
| Implemented |
| 6400.166(b) | According to the date and initials of staff written on the dispensed blister pack, Individual #1's prescribed pro re nata medication, Hydroxyz Pam Cap. 25 MG---Take 1 capsule by mouth three times a day as needed for excessive anxiety---had been last administered on 6/22/25. However, Individual #1's June 2025 Medication Administration Record in Therap was not initialed, documenting the administration of this medication. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The staff responsible was retrained on the requirement to document MAR entries at the
time of administration.
The Nurse Coordinator reviewed Individuals MAR to ensure no further late entries
occurred. |
09/01/2025
| Implemented |
| 6400.166(c) | On 7/23/25, Individual #1's July 2025 Medication Administration Record in Therap revealed that the following medications on the following dates and times were marked "M/R," meaning missed or refused: Clotrimazole Cream 1% Topical Cream: (at 8 AM) on 7/8/25, 7/10/25, 7/14-15/25, 7/17/25, 7/19/25, and 7/22-23/25; (at 8 PM): on 7/13-1/4/25; Diclofenac Gel 1%: (at 8 AM) on 7/3/25, 7/8/25, 7/10/25, 7/14-15/25, 7/19/25, and 7/22-23/25; (at 8 PM) on 7/13/25; Fluoxetine 20 MG Cap.: (at 8 AM) on 7/23/25; Hydroxyz Pam. 50 MG Cap.: (at 2 PM) on 7/11/25 and 7/17/25; and Terbinafine 1% Cream: (at 8 AM) on 7/10/25, 7/14-15/25, 7/17/25, 7/19/25; (at 8 PM) on 7/13-14/25. Agency interviews conducted revealed that these medications marked "M/R" on the above dates and times had been refused by Individual #1. However, the agency did not provide documentation notifying the prescriber of Indivudal#1's recorded medication refusals. | 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. | Individual¿s physician was contacted regarding the refused doses.
Staff were retrained on the requirement to document (refusal) in the comment section in Therap.
They are to then notify house manager so they can notify the prescriber of the
refusal. |
09/05/2025
| Implemented |
| 6400.182(c) | Individual #1's Service Plan, last updated 6/19/25, contained the following discrepancies between their initial and current assessment, completed on 2/14/25, in the following health and safety skill domains: regarding poisonous materials, Individual #1's Service Plan, last updated 6/19/25, stated only that "[Individual #1] would not knowingly ingest a non-food item. [They] would not ingest a poisonous item." However, Individual #1's assessment, completed on 2/14/25, indicated, "No," in relation to Individual #1 having the ability to safely use or avoid poisonous materials, and added that "[Individual #1] requires supervision when using household cleaning supplies."; regarding supervision within the home, Individual #1's Service Plan, last updated 6/19/25, explained that they require 22-hour supervision and that staff prompting is needed to ensure Individual #1's completion of daily living skills. In contrast, Individual #1's assessment, completed on 2/14/25, informed that Individual #1 requires 24-hour supervision for their safety and wellbeing while at home; and regarding supervision within the community, Individual #1's Service Plan, last updated 6/19/25, indicated only two hours of supervision is needed and added, "It is vital that supports are present when [Individual #1] is outside [their] residence and in the community." However, Individual #1's assessment, completed on 2/14/25, informed that Individual #1 requires 24-hour supervision for their safety and wellbeing when in the community. [Repeated Violation-7/30/24 et al.] | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | In the future, the Program Specialist will submit an assessment cover page to the individual¿s Support Coordinator and treatment team, which includes the following:
o Lifetime Medical History
o Yearly Doctor Appointments
o Psychological Evaluation
o Current List of Medications
A copy of the Assessment Cover Page Checklist will be sent to the Department. |
09/01/2025
| Implemented |
| 6400.195(a) | Individual #1's Service Plan, last updated 6/19/25, states the following in regard to sharps: "[Individual #1] relies on others to use knives for [Individual #1]." "Present concerns are emotional outbursts and impulsivity." "[Individual #1] has a history of aggressive behaviors (throwing chairs, slapping staff, etc.)." At 12:04 PM on 7/23/25, steak knives, cooking knives, and other sharp objects were locked in a cabinet located in the staff office. However, Individual #1 does not currently have a restrictive procedure plan approved by the human rights team, limiting access to these sharp objects. | For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures. | Restrictive Procedure Plan has been developed. All staff have been trained on restrictive procedure plan. Locking sharps is part of the restrictive procedure plan. LRS HRT has approved the plan.
Minutes and BSC's training sign in sheet will be sent to the Department. |
10/01/2025
| Implemented |