| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(b) | On 5/4/2025 at 11:06AM, there was an inordinate amount of dead insects and spiders on the floor along the baseboards in the garage of the home. | There may not be evidence of infestation of insects or rodents in the home. | On 6/10/2025, the garage was thoroughly cleaned and vacuumed, with special attention paid to the baseboards and floor areas where the deceased insects and spiders were noted. |
06/10/2025
| Implemented |
| 6400.65 | On 6/4/2025 at 11:03AM, the cover of the mechanical ventilation fan in the bathroom in the basement of the home was coated with a thick layer of lint preventing it from fully functioning. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| The lint buildup on the mechanical ventilation fan in the basement bathroom was removed on 6/10/2025. The fan was cleaned and tested to ensure it is functioning properly and providing adequate ventilation. |
06/10/2025
| Implemented |
| 6400.214(a) | The most recent copy of Individual #1's Social, Emotional, Environmental Plan was not present at the home. | Record information required in § 6400.213(1) (relating to content of records) shall be kept at the home. | The missing Social, Emotional, Environmental Plan for Individual #1 was located and reviewed. A copy of the updated plan was printed and placed in the home record on June 10, 2025. All staff at the residence were informed of the update and the location of the document. |
06/10/2025
| Implemented |
| 6400.50(a) | The records of annual training year, 1/1/2024 through 12/31/2024, for Direct Service Worker #1 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 |
| 6400.52(c)(5) | Direct Service Worker #1, date of hire 10/5/2023, 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. | Direct Service Worker #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 Direct Service Worker #1 was completed during annual training year 2024 however, proper documentation was not maintained in the employee file. |
06/14/2025
| Implemented |
| 6400.52(c)(6) | Direct Service Worker #1, date of hire 10/5/2023, was not trained on the Implementation of the individual plan for 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. | Direct Service Worker #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 and desired outcomes.
Annual training for Direct Service Worker #1 was completed during annual training year 2024 however, proper documentation was not maintained in the employee file. |
06/14/2025
| Implemented |