| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | Two spray bottles that were hand-lettered "bleach water/shower table" and "floor cleaner" were found stored with the cleaning supplies in the laundry/utility room. | Poisonous materials shall be stored in their original, labeled containers. | Disposed of unlabeled/hand-labeled bottles and communicated to the care team that they may use only original manufacturer containers with intact labels. Was completed on 8/1/25, new manufacturer labeled bottles arriving with August supply order. |
08/15/2025
| Implemented |
| 6400.73(a) | The basement stairway leading to a bilco-style door exit to the outside had nine steps and there was no handrail. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | Maintenance Department will install a secure handrail meeting ADA regulations and standards. |
08/25/2025
| Implemented |
| 6400.113(a) | Individual #1 was admitted on 4/02/2025 and did not receive fire safety training until 7/07/2025. Individual #2 was admitted on 5/06/2025 and did not receive fire safety training until 7/07/2025. | 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. | Fire safety training will be completed on the day of admission, along with admission paperwork/protocols. |
08/11/2025
| Implemented |
| 6400.151(a) | Staff #2 was hired on 4/04/2025 and there was no documentation that the staff had a physical examination within 12 months prior to employment. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Staff #2 will complete their Physical Re-Examination for 8/28/2025, will not work at location until complete. |
08/28/2025
| Implemented |
| 6400.151(c)(2) | Staff #2 was hired on 4/04/2025 and there was no documentation that the staff had tuberculin skin testing within 12 months prior to employment.
Staff #3 was hired on 4/07/2025 and there was no documentation that the staff had tuberculin skin testing within 12 months prior to employment. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | Obtain and file updated Mantoux test with physical exam for Staff #2, and Staff #3. |
08/22/2025
| Implemented |
| 6400.15(b) | The agency did not use the Department's licensing inspection instrument when completing the self-assessment prior to the renewal inspection. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | Correct, department-approved self inspection tool was located on 7/22/2025, and completed on 7/29/2025. |
07/29/2025
| Implemented |
| 6400.34(a) | Individual #2 was admitted on 5/06/2025 and the home did not inform and explain individual rights and the process to report a rights violation to the individual until 5/07/2025. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Rights explanation and documentation will occur during the admission process before the individual enters the home. |
07/25/2025
| Implemented |
| 6400.46(d) | Staff #1 was hired on 7/15/2024 and there was no documentation to show that the staff was trained in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Staff #1 will obtain CPR and First Aid training on 8/23/2025 and file training documentation upon receipt. |
08/25/2025
| Implemented |
| 6400.163(d) | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. Per the Chapter 6400 Regulatory Compliance Guide, for medications that are controlled substances, an "area or container that is locked" must include a "double locking" mechanism such as storing the controlled substance(s) in a locked container within a locked area. At the time of the inspection, the controlled substances prescribed for Individual #1 and #2 were not stored with a double locking mechanism. The controlled substances were stored single locked in a file cabinet drawer. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | A second locked box has been ordered and will be placed inside the existing locked medication cabinet. All controlled substances will be transferred into the inner locked box upon installation, ensuring double-lock compliance. |
08/25/2025
| Implemented |
| 6400.163(f) | At the time of the inspection, refrigerated medications such as glycerin suppositories prescribed for Individual #1 and #2, and Humulin brand insulin prescribed for Individual #2 were stored in the kitchen area in a small refrigerator that had an inoperable locking mechanism. | Prescription medications stored in a refrigerator shall be kept in an area or container that is locked. | Replacement of the refrigerator lock is scheduled for 8/26/2025. Until the repair is complete, all refrigerated medications will be stored in an alternate locked refrigerator. |
08/26/2025
| Implemented |