| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(a) | 6 out of the 12 monthly fire drills were held in the presence of Individual #1 during the past twelve months. The Individual does not reside in this home. The agency stated that the individual likes to help with fire drills and therefore this acts to announce to the residents of the home that there will be a drill held during Individual #1's visit. | An unannounced fire drill shall be held at least once a month. | ·All staff were retrained on 9/5/2025 with 6400 regulations fire safety section. A sleep fire drill and awake was completed to show the individuals that only reside in the home participated in the drills. |
09/05/2025
| Implemented |
| 6400.112(c) | 11 of the 12 drills held during the past year did not have the address of the home but one of the individual's names. | 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. | ·All Staff members completed retraining on Section 6400 of the fire safety regulations on September 5, 2025. Provider carried out both a sleep-mode fire drill and an awake fire drill- using the facility's actual address and layout, full participation with the individuals residing in the home |
10/06/2025
| Implemented |
| 6400.112(e) | Between the period of 12/2024 and 8/2025 a drill was not conducted during sleeping hours. | A fire drill shall be held during sleeping hours at least every 6 months. | ·All Staff members completed retraining on Section 6400 of the fire safety regulations on September 5, 2025. Provider carried out a sleep-mode fire drill using the facility's actual address and layout, full participation with the individuals residing in the home |
10/06/2025
| Implemented |
| 6400.141(a) | There was no current physical exam for Individual #4. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #4 completed a physical at the urgent Care 10/6/2025. A copy of the form is kept in a file at the office. |
10/06/2025
| Implemented |
| 6400.141(c)(7) | There was no GYN exam in the record for Individual #4. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Individual #4 attended GYN appointment; documentation filed. Individual #4 completed her annual GYN appointment on 12/12/2024. |
09/05/2025
| Implemented |
| 6400.181(a) | Individual #4's last three annual assessments have not changed. Since the 2023 the assessment, subsequent documents have been word for word verbatim. | 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. | On 9/3/25 Program Specialist and CEO Updated assessment to reflect current information on individual #4. |
09/04/2025
| Implemented |
| 6400.181(e)(12) | Under this section of the annual assessment " No recommendations for specific services at this time" has been recorded for the past three assessments for Individual #4. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | 9/3/25 Program Specialist and CEO Revised assessment to include individual #4 recommendations per her ISP. |
09/04/2025
| Implemented |
| 6400.181(e)(13)(i) | There has been no progress and growth changes recorded since 2023 for Individual #3 on assessments completed. | 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.
| On 9/3/2025, CEO and Program Specialist updated the assessment with current information to reflect progress and growth with individual #3. |
09/04/2025
| Implemented |
| 6400.165(g) | Individual #4 who is on psychotropics medications and has a behavioral support plan did not have psychotropic medication reviews on record. | 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. | On 9/3/2025 nurse and Program Specialist retrieved all psychotropic reviews 12/24, 3/25, 6/25 and 9/25 obtained and added to chart. |
09/04/2025
| Implemented |
| 6400.166(a)(11) | The purpose/diagnosis for all medications are missing from the MAR for Individual #4. | 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. | All MARs updated to include medication purposes/diagnosis on 10/1/2025. |
10/09/2025
| Implemented |
| 6400.182(c) | The ISP for Individual #4 states that the supervision level is 2:1. Yet the assessment and other records state that the level is 1:1. PS stated that it has been 1:1 for 2 ½ years. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | On 9/4/2025 The CEO asked the Support Coordinator to amend the updated! SP, changing the supervision level from 2:1 to the correct 1:1 ratio via email. ISP has been changed and updated as of 10/06/2025. |
10/06/2025
| Implemented |
| 6400.183(c) | There was no sign-in sheet for the ISP dated 8/7/25 for Individual #4. | The list of persons who participated in the individual plan meeting shall be kept. | On 9/23/2025 CEO met with Support Coordinator requesting copy of the sign-in sheet for Individual #4. Provider received a copy of the ISP meeting signature sheet on 10/6/2025. |
10/06/2025
| Implemented |
| 6400.186 | The ISP for Individual #4 states that the supervision level is 2:1. Yet the assessment and other records state that the level is 1:1. PS stated that it has been 1:1 for 2 ½ years. | The home shall implement the individual plan, including revisions. | On 9/4/2025 The CEO asked the Support Coordinator to amend the updated! SP, changing the supervision level from 2:1 to the correct 1:1 ratio via email. ISP has been changed and updated as of 10/06/2025. |
10/06/2025
| Implemented |