| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(a) | At 11:22AM on 6/24/2026, the hot water temperature measured 97.5 degrees Fahrenheit at the bathtub in the ensuite bathroom. At 11:26AM, the hot water temperature measured 96.8 degrees Fahrenheit at the bathtub in the bathroom in the hallway of the home. At 11:29AM, the hot water temperature measured 96.4 degrees Fahrenheit at the sink in the kitchen of the home. | A home shall have hot and cold running water under pressure. | MAINTENANCE WAS CONTACTED AND AN ORDER WAS MADE TO ADJUST THE HOT WATER TO AN ACCEPTABLE TEMPERATURE. MAINTENANCE CAME OUT THAT DAY AND ADJUSTED THE WATER TEMPERATURE TO 120 DEGREES. |
07/15/2026
| Implemented |
| 6400.106 | The agency did not provide documentation of furnace inspections; therefore, complaince could not be measured. | 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.
| DOCUMENTATION FOR REQUIRED ANNUAL INSPECTION WAS LOCATED AT END OF DAY AFTER INSPECTION SHOWING PROOF THAT THE AGENCY WAS IN COMPLIANCE. DOCUMENTATION WAS EMAILED TO INSPECTOR. |
07/29/2026
| Implemented |
| 6400.142(d) | Individual #1 had a dental examination that included teeth cleaning on 5/20/2025 and then again on 6/16/2026. | The dental examination shall include teeth cleaning or checking gums and dentures. | INDIVIDUAL #1 HAS BEEN SEEN BY THE DENTIST WITHIN THE PAST YEAR. |
07/10/2026
| Implemented |
| 6400.151(b) | Program Specialist #1 had a physical examination, completed 1/15/2025, was not dated by the licensed physician, certified nurse practitioner or licensed physician's assistant. Direct Service Worker #2 had a physical examination completed, 9/30/2025, was not dated by the licensed physician, certified nurse practitioner or licensed physician's assistant. Direct Service Worker #3 had a physical examination completed 10/20/2025 that was not dated by the licensed physician, certified nurse practitioner or licensed physician's assistant. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | AGENCY PHYSICAL FORM HAS BEEN REVISED TO ADD THE NAME AND SIGNATURE OF THE LICENSED PROFESSIONAL WHO IS PERFORMING THE EXAM ON THE SAME LINE. THE NEWLY- CREATED FORM WAS EMAILED TO THE INSPECTOR ON JUNE 25, 2026. |
07/29/2026
| Implemented |
| 6400.181(e)(1) | Individual #2's assessment, completed 3/5/2026, does not include the individual's preferences. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | THE PROGRAM SPECIALIST HAS IMMEDIATELY UPDATED THE TEMPLATE FOR ASSESSMENTS TO MIRROR THE REGULATIONS. |
07/29/2026
| Implemented |
| 6400.32(e) | Individual #2's record contained a document entitled, "House Rules," signed by Program Specialist #1 and Individual #2 on 12/12/2025. The rules included, but were not limited to, "visitors to be screened accordingly." This rule prohibits the individual's right to make choices and accept risks. | An individual has the right to make choices and accept risks. | THE HOUSE RULES FOR ABUNDANT LIVING-MCCCANDLESS TOWNSHIP HAS BEEN MODIFIED BOTH IN TITLE AND CONTENT IN ORDER TO BE CONSISTENT WITH THE INDIVIDUAL RIGHTS. THIS DOCUMENT IS NOW REFERRED TO AS HOUSE GUIDELINES TO BECOME MORE CONSISTENT WITH THEIR INTENT. THE LANGUAGE IN THE GUIDELINES REFERRING TO "VISITORS TO BE SCREENED ACCORDINGLY" HAS BEEN REMOVED FROM THE DOCUMENT. [The agency is not using guidelines for individuals and will inform and explain Individual rights as per Chapter 6400 Regulations. (AES,HSLS on 8/13/2026)] |
07/19/2026
| Implemented |
| 6400.32(l) | Individual #2's record contained a document entitled, "House Rules," signed by Program Specialist #1 and Individual #2 on 12/12/2025. The rules included, but were not limited to, "visitors to be screened accordingly." This rule prohibits the individuals right receive scheduled and unscheduled visitors, and to communicate and meet privately with whom the individual chooses, at any time. | An individual has the right to receive scheduled and unscheduled visitors, and to communicate and meet privately with whom the individual chooses, at any time. | THE HOUSE RULES FOR ABUNDANT LIVING-MCCCANDLESS TOWNSHIP HAS BEEN MODIFIED BOTH IN TITLE AND CONTENT IN ORDER TO BE CONSISTENT WITH THE INDIVIDUAL RIGHTS. THIS DOCUMENT IS NOW REFERRED TO AS HOUSE GUIDELINES TO BECOME MORE CONSISTENT WITH THEIR INTENT. THE LANGUAGE IN THE GUIDELINES REFERRING TO "VISITORS TO BE SCREENED ACCORDINGLY" HAS BEEN REMOVED FROM THE DOCUMENT.[The agency is not using guidelines for individuals and will inform and explain Individual rights as per Chapter 6400 Regulations. (AES,HSLS on 8/13/2026)] |
07/19/2026
| Implemented |
| 6400.52(c)(6) | Program Specialist #1's annual training completed from 7/1/2024 through 6/30/2025 did not include training in implementation of the individual plans for the individuals she works directly with. | 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. | DURING THE 7/1/2024 -- 6/30/25 TRAINING YEAR, THE PROGRAM SPECIALIST RECEIVED A TOTAL OF 32.5 HOURS OF TRAINING. THE IMPLEMENTATION OF THE INDIVIDUAL PLANS TRAINING OCCURRED ON FEBRUARY 27, 2025. SEE ATTACHED TRAINING SHEET. |
06/24/2026
| Implemented |
| 6400.163(a) | Individual #2's assessment, completed 3/5/2026, and staff interviews revealed that Individual #2 removes their medications in advance every week, puts them into a pill organizer with staff assistance and then takes the medications daily with staff assistance. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | INDIVIDUAL # 1 IS NOT A SELF-ADMINISTERING CLIENT AND RECEIVES MEDICATION ADMINISTRATION SERVICES FROM STAFF. INDIVIDUAL #2 IS NOT LISTED ON THE POC REPORT. IND #2 IS SELF-
ADMINISTERING CONSUMER. THE CONSUMER HAS BEEN ADVISED THAT SHE WILL NO LONGER RECEIVE ASSISTANCE REMOVING MEDICATIONS FROM THE ORIGINAL CONTAINERS BUT WILL NEED TO TAKE THEM AS PRESCRIBED FROM THEIR ORIGINAL CONTAINERS. |
07/10/2026
| Implemented |
| 6400.166(a)(15) | Individual #1 is prescribed Miralax for constipation. The physician's orders state, "Miralax 2 capfulls daily if [patient] having loose stools, can decrease by 1/2 cap in 1 week. If [patient] having constipation increase to 1 1/2 capfuls BID in one week. Only make 1 change weekly." Individual #1's June 2026 Medication Administration Record states, "Dissolve 34 grams into 8 ounces of fluid and drink by mouth once daily every morning." The special precautions were not documented on the Medication Administration Record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Special precautions, if applicable. | THE PCP PROVIDED A NEW PRESCRIPTION FOR THE MIRALAX AND THE NEW LABEL HAS BEEN APPLIED TO THE MEDICATION. THE MAR HAS BEEN UPDATED TO REFLECT THE NEW PRESCRIPTION ORDER. |
07/15/2026
| Implemented |
| 6400.213(7) | Individual #1's record did not include the invitation letter to Individual #1's most recent service plan meeting. | Each individual's record must include the following information: Individual plan documents as required by this chapter. | THE ISP MEETING FOR INDIVIDUAL 1 OCCURRED ON 3/20/26 BASED ON COMMUNICATION THE PS HAD WITH THE SC VIA EMAIL ON 12/15/25 THE INVITATION LETTER DATED 1/6/2026 WAS RECEIVED BY THE PROGRAM SPECIALIST. THE INVITATION LETTER HAD A TYPO ON THE DATE OF THE MEETING AND SUBSEQUENT REFERENCE TO THE DATE OF THE MEETING. IT LISTED 3/20/25 INSTEAD OF THE ACTUAL DATE OF 3/20/26 WHICH IS IN THIS CURRENT YEAR. MEETING. IT LISTED 3/20/25 INSTEAD OF THE ACTUAL DATE OF 3/20/26 WHICH IS IN THIS CURRENT YEAR. |
06/24/2026
| Implemented |