| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | There's a foul odor of sewer in the basement; the floor has a small flood with wet toilet paper on the floor. | Clean and sanitary conditions shall be maintained in the home. | The affected basement area was immediately cleaned and sanitized, including removal of debris and contaminated materials.
Maintenance was notified to inspect the floor drain and plumbing system to identify and correct the source of the sewer odor.
Necessary repairs and/or cleaning of the drainage system were completed to eliminate the odor and restore sanitary conditions.
Staff were instructed to promptly report any environmental or sanitation concerns.
The Compliance Officer began development of a tracking system for environmental issues to ensure timely identification and resolution. |
04/24/2026
| Implemented |
| 6400.67(b) | The lint trap is full of lint. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The lint trap was immediately cleaned and cleared of all lint.
The dryer and surrounding area were inspected to ensure safe operation.
Maintenance staff were instructed to monitor and maintain laundry equipment regularly.
Staff were trained on the importance of cleaning the lint trap after each use and reporting any environmental or safety concerns.
The Compliance Officer initiated development of a tracking system for environmental and maintenance issues. |
01/20/2026
| Implemented |
| 6400.71 | There were no emergency numbers by the telephone. | 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.
| Emergency contact numbers (including fire department, police, ambulance, poison control, and provider contacts) were posted by all telephones in the home.
Maintenance was instructed to securely install and mount the emergency numbers to prevent removal.
It was identified that the posting had previously been removed due to an individual's behavior; therefore, additional measures were implemented to ensure postings are secured and monitored regularly.
Staff were trained on the importance of ensuring emergency information remains posted and immediately reporting if it is removed or damaged.
The Compliance Officer initiated development of a tracking system for environmental and safety concerns. |
01/20/2026
| Implemented |
| 6400.73(a) | Stairwell leading to the 2nd floor apartment has no rails, stairwell to the basement has no rails. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | Maintenance was instructed to install secure handrails on both the stairwell leading to the 2nd floor and the stairwell leading to the basement.
Installation will be completed in accordance with safety standards and building requirements to ensure stability and proper use.
Staff were trained on the importance of identifying and reporting environmental and safety hazards promptly.
The Compliance Officer initiated development of a tracking system for environmental and safety concerns to ensure timely resolution of identified issues. |
03/25/2026
| Implemented |
| 6400.74 | There's no nonskid traction on the stairs leading to the basement, the outdoor stairs leading to the 2nd Floor apartment and the interior stairs leading to 2nd floor | Interior stairs and outside steps shall have a nonskid surface.
| Maintenance was instructed to install appropriate nonskid traction (e.g., adhesive strips, treads, or coatings) on all identified stairways.
All installations will be completed in accordance with safety standards to ensure durability and effectiveness.
Staff were trained on the importance of identifying and reporting environmental and safety hazards promptly.
The Compliance Officer initiated development of a tracking system for environmental and safety concerns to ensure timely correction of hazards. |
01/25/2026
| Implemented |
| 6400.77(b) | There is No Thermometer available in the home. | 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. | ASO purchased and placed a thermometer in the home's first aid kit to ensure compliance.
The first aid kit was reviewed to confirm all required items are present and complete.
Staff were trained on the importance of maintaining complete first aid supplies and reporting any missing items immediately.
The Compliance Officer initiated development of a tracking system for environmental and safety concerns, including monitoring of first aid supplies. |
01/21/2026
| Implemented |
| 6400.82(f) | The bathroom in the basement do not have any toilet paper | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | ASO immediately stocked the basement bathroom with toilet paper to ensure availability.
All bathrooms in the home were reviewed to confirm adequate supplies are present and accessible.
Staff were trained on the importance of maintaining adequate bathroom supplies and promptly reporting any deficiencies.
The Compliance Officer initiated development of a tracking system for environmental and supply-related concerns to ensure timely replenishment and monitoring. |
01/21/2026
| Implemented |
| 6400.104 | ·There was no notification letter to the FD. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| ASO prepared and submitted a notification letter to the local fire department informing them of the home's location, occupancy, and use.
Documentation of the notification was placed in the facility binder for verification and ongoing compliance.
Staff were trained on the importance of maintaining required safety documentation and reporting any deficiencies immediately.
The Compliance Officer initiated development of a tracking system for environmental and safety documentation requirements. |
01/22/2026
| Implemented |
| 6400.106 | ·No furnace inspection was found in the binder | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| ASO scheduled and completed a furnace inspection and cleaning by a licensed HVAC professional.
Documentation of the inspection and cleaning was obtained and placed in the facility binder for compliance verification.
Staff were trained on the importance of maintaining required environmental and safety documentation and reporting deficiencies immediately.
The Compliance Officer initiated development of a tracking system for environmental maintenance and inspection requirements, including furnace inspections. |
01/27/2026
| Implemented |
| 6400.111(a) | The attic has no fire extinguisher. A fire extinguisher was placed in the attic after the inspection. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | A fire extinguisher was placed in the attic immediately following the inspection to ensure compliance.
The fire extinguisher was verified to be fully charged, accessible, and properly mounted.
All fire extinguishers throughout the home were reviewed to ensure proper placement and compliance.
Staff were trained on the importance of fire safety equipment, proper use of extinguishers, and reporting any missing or damaged equipment immediately.
The Compliance Officer initiated development of a tracking system for environmental and fire safety equipment. |
01/20/2026
| Implemented |
| 6400.112(a) | ·October and November drills did not have any paperwork or did not occur. | An unannounced fire drill shall be held at least once a month. | ASO conducted fire drills to address the missed months and ensured proper procedures were followed.
Documentation was completed and placed in the facility binder for all required fire drills.
Staff were retrained on the importance of conducting and properly documenting monthly fire drills.
The Compliance Officer initiated development of a tracking system for fire drills and safety documentation to ensure drills are conducted and recorded timely. |
01/20/2026
| Implemented |
| 6400.141(c)(3) | The 01/02/26 Annual Physical Examination for individual 1 did not include information regarding immunizations for individuals 18 years of age or older. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | ASO will request updated medical documentation from the healthcare provider to include complete immunization information for Individual 1.
The updated physical examination record will be placed in the individual's file to ensure compliance.
A review of all individual health records will be conducted to ensure immunization documentation is complete for all individuals served.
The Compliance Officer will reinforce the importance of complete medical documentation and its role in ensuring client health and safety with staff and administrative personnel. |
01/30/2026
| Implemented |
| 6400.141(c)(4) | The 01/02/26 Annual Physical Examination for individual 1 did not include a vision and hearing screening. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | ASO will request updated medical documentation from the healthcare provider to include completed vision and hearing screening results for Individual 1.
The updated documentation will be placed in the individual's record to ensure compliance.
A review of all individual health records will be conducted to ensure vision and hearing screenings are documented where required.
The Compliance Officer will reinforce the importance of complete medical documentation and its role in ensuring client safety with staff and administrative personnel. |
01/30/2026
| Implemented |
| 6400.141(c)(6) | The 01/02/26 Annual Physical Examination for individual 1 did not include Tuberculin skin testing. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | ASO will request updated medical documentation from the healthcare provider to include a completed tuberculin skin test (or appropriate alternative screening) for Individual 1.
The updated documentation will be placed in the individual's record to ensure compliance.
A review of all individual health records will be conducted to ensure tuberculosis screening requirements are completed and documented for all individuals served.
The Compliance Officer will reinforce the importance of complete medical documentation and communicable disease prevention with staff and administrative personnel to ensure client safety. |
01/30/2026
| Implemented |
| 6400.141(c)(13) | The 01/02/26 Annual Physical Examination for individual 1 did not include information regarding allergies or contraindicated medications. | The physical examination shall include: Allergies or contraindicated medications. | ASO will request updated medical documentation from the healthcare provider to include complete information regarding allergies and contraindicated medications for Individual 1.
The updated documentation will be placed in the individual's record to ensure compliance.
A comprehensive review of all individual health records will be conducted to ensure allergy and medication contraindication information is documented for all individuals served.
The Compliance Officer will reinforce the importance of complete medical documentation and its role in preventing medication-related risks and ensuring client safety with staff and administrative personnel. |
01/30/2026
| Implemented |
| 6400.141(c)(14) | The 01/02/26 Annual Physical Examination for individual 1 did not include information regarding medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | ASO will request updated medical documentation from the healthcare provider to include all required emergency medical information, including diagnosis and treatment considerations.
The updated documentation will be placed in the individual's record to ensure compliance.
A comprehensive review of all individual health records will be conducted to ensure emergency medical information is complete and current for all individuals served.
The Compliance Officer will reinforce the importance of complete medical documentation and emergency preparedness with staff and administrative personnel to ensure client safety. |
01/30/2026
| Implemented |
| 6400.144 | There is no 11/18/25 dental follow up that was ordered for individual 1.
Individual 1's 09/12/25 psychiatric medication review states to follow up in 1 month and there were no follow-up appointments since then. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| ASO will schedule and ensure completion of the required dental follow-up appointment for Individual 1.
ASO will schedule and ensure completion of the required psychiatric follow-up appointment, including medication review as recommended.
Documentation of all completed appointments will be placed in the individual's medical record.
A comprehensive review of all individuals' medical records will be conducted to ensure all ordered follow-up appointments are scheduled, completed, and documented.
The Compliance Officer will reinforce the importance of timely follow-up care and documentation with staff and administrative personnel to ensure client health and safety. |
01/30/2026
| Implemented |
| 6400.181(a) | There was no annual assessment in file. | 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. | ASO will complete and update the required annual assessments for the individual(s) to ensure compliance.
Completed assessments will be placed in the individual's file and reviewed for accuracy and completeness.
A comprehensive review of all individual records will be conducted to ensure all annual assessments are current and properly documented.
The Compliance Officer will reinforce the importance of timely completion of annual assessments and documentation with staff and administrative personnel to ensure client safety and proper care planning. |
04/30/2026
| Implemented |
| 6400.217 | The release of information form was not signed by individual 1, but was signed by the individual's mother. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| ASO will obtain a properly completed and signed release of information form from Individual 1, if the individual is legally able to provide consent.
If Individual 1 is not legally able to provide consent, ASO will ensure appropriate legal documentation (e.g., guardianship or power of attorney) is obtained and maintained to support authorized signatures.
The updated and compliant documentation will be placed in the individual's record.
A comprehensive review of all individual records will be conducted to ensure all release of information forms are properly signed and compliant.
The Compliance Officer will reinforce the importance of protecting individual rights, confidentiality, and proper authorization procedures with staff and administrative personnel. |
01/20/2026
| Implemented |
| 6400.34(a) | Individual 1's individual rights form did not include the right to access food at any time [6400.32(t)]. | 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. | ASO will update Individual 1's rights form to include all required rights, including the right to access food at any time.
The updated rights form will be reviewed with Individual 1 to ensure understanding, and properly signed and placed in the individual's record.
A comprehensive review of all individuals' rights forms will be conducted to ensure all required rights are fully documented and compliant.
The Compliance Officer will reinforce the importance of protecting individual rights and maintaining accurate documentation with staff and administrative personnel to ensure client safety and dignity. |
01/30/2026
| Implemented |
| 6400.165(g) | There were no psychiatric medication reviews done for individual 1 since 09/12/25. | 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. | ASO will schedule and ensure completion of a psychiatric medication review for Individual 1 by a qualified professional.
Documentation of the completed review will be placed in the individual's medical record.
A comprehensive review of all individuals' records will be conducted to ensure psychiatric medication reviews are current and completed as required.
The Compliance Officer will reinforce the importance of timely psychiatric follow-ups and proper documentation with staff and administrative personnel to ensure client safety. |
04/30/2026
| Implemented |
| 6400.213(1)(i) | Individual 1's records did not address if the individual has any identifying marks. | Each individual's record must include the following information: Personal information, including: (ii) The race, height, weight, color of hair, color of eyes and identifying marks. | ASO updated Individual 1's face sheet to include information regarding identifiable marks (or documented "none" if applicable), ensuring the record is complete and accurate.
The individual's binder was reviewed to confirm all required elements are properly documented and compliant.
The Training/Compliance Officer and HR managers were instructed and retrained on documentation requirements, emphasizing the importance of complete and accurate records to support client safety and identification needs. |
01/22/2026
| Implemented |