| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(c) | The agency's self-assessment completed for this home between 7/10/25 to 7/11/25, did not provide a written summary of corrections for the following regulation items identified as violations: .165g and .181e10. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| A written summary of corrections to the violations identified in the agency¿s self-assessment has been provided to the POCs. |
08/26/2025
| Implemented |
| 6400.111(f) | On 7/23/25, the apartment unit's only fire extinguisher located in the kitchen was last inspected and approved by a fire safety expert in June 2024. [Repeated Violation-7/30/24 et al.] | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | On July 24, 2025, the fire extinguisher was promptly inspected and recertified by a licensed fire safety technician.
A copy of the inspected fire extinguisher will be sent the Department. |
09/05/2025
| Implemented |
| 6400.112(c) | According to the written fire drill record submitted from 7/24/24 to 7/1/25, the drill conducted on 9/7/24 did not document the time it took place, as the corresponding field was left blank. [Repeated Violation-7/30/24 et al.] | 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. | The missing time field for the 9/7/24 drill was corrected based on staff recollection and available documentation. All staff responsible for conducting and recording fire drills were retrained on proper documentation procedures, including the importance of completing every required field. This includes the date, time, duration of evacuation, exit route used, problems encountered, and whether the fire alarm or smoke detector was operational.
A copy of the missing time fire drill will be sent to the Department. |
09/05/2025
| Implemented |
| 6400.113(a) | Individual #1's date-of-admission is 1/28/25. Their initial fire safety training completed on 1/28/25, did not address the following required content relative to their place of residence: 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. [Repeated Violation-7/30/24 et al.] | 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. | The individual completed an updated fire safety training that includes content related to their place of residence: 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 procedures if the individuals smoke at home.
The updated fire training safety training signed by individual will be sent to the Department. |
09/01/2025
| Implemented |
| 6400.141(c)(6) | Individual #1's date-of-admission is 1/28/25. Their content of records included documentation of a tuberculin skin test via Mantoux method that was planted on 1/1/25 at 4:47 PM and read with negative results on 1/1/25 at 4:48 PM. | 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. | The House Manager has been trained on 6400.141(c)(6) requirements.
Staff accompanying an individual to a medical provider appointment will be trained to review documentation and paperwork before leaving the office. |
09/01/2025
| Implemented |
| 6400.141(c)(11) | Individual #1's date-of-admission is 1/28/25. Individual #1's physical examination, completed on 12/31/24, did not include their medication regimen, as the "Medications" field read: "See attached." However, a list of Individual #1's medications was not attached to this physical examination. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | - Staff was instructed to adhere to the interim daily oral care protocol until the dental hygiene plan is completed. |
09/01/2025
| Implemented |
| 6400.142(g) | Individual #1's current assessment, completed on 3/28/25, indicates that they require verbal prompts to complete oral hygiene. However, Individual #1's content of records did not include a written dental hygiene plan. | A dental hygiene plan shall be rewritten at least annually. | - Staff were instructed to adhere to the interim daily oral care protocol until the dental hygiene plan is completed. |
09/01/2025
| Implemented |
| 6400.181(e)(11) | Individual #1's date-of-admission is 1/28/25. Their assessment completed on 3/28/25, did not include an applicable psychological evaluation. | The assessment must include the following information: Psychological evaluations, if applicable. | In the future, the Program Specialist will submit an assessment cover page to the individual¿s Support Coordinator and treatment team, which includes the following:
o Lifetime Medical History
o Yearly Doctor Appointments
o Psychological Evaluation
o Current List of Medications
A copy of the Assessment Cover Page Checklist will be sent to the Department. |
09/01/2025
| Implemented |
| 6400.32(r)(1) | At 1:42 PM on 7/23/25, the privacy door lock to Individual #2's bedroom was equipped with a turn latch on the inside and a straight-edge, thumbnail access point on the entry side. This bedroom door locking system does not provide Individual #2 with a unique mechanism or entry device to lock and unlock their bedroom door. At 1:45 PM on 7/23/25, the privacy door lock to Individual #1's bedroom was equipped with a turn latch on the inside and a pinhole access point on the entry side. This bedroom door locking system does not provide Individual #1 with a unique mechanism or entry device to lock and unlock their bedroom door. | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | A new locking mechanism was installed allowing immediate access by the individual and staff in the event of an emergency.
A picture of the doorknob allowing immediate access will be sent to the Department. |
09/01/2025
| Implemented |
| 6400.32(r)(4) | At 1:42 PM on 7/23/25, the privacy door lock to Individual #2s bedroom was equipped with a turn latch on the inside and a straight-edge, thumbnail access point on the entry side. This bedroom door locking system does not allow easy and immediate access by the individual and staff persons in the event of an emergency. At 1:45 PM on 7/23/25, the privacy door lock to Individual #1's bedroom was equipped with a turn latch on the inside and a pinhole access point on the entry side. This bedroom door locking system does not allow easy and immediate access by the individual and staff persons in the event of an emergency. | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. | A new locking mechanism was installed allowing immediate access by the individual and staff in the event of an emergency.
A picture of the doorknob allowing immediate access will be sent to the Department. |
09/01/2025
| Implemented |
| 6400.165(g) | Individual #1's date-of-admission is 1/28/25, and they are prescribed medication to treat symptoms of a psychiatric illness. However, Individual #1 medications were last reviewed by a licensed physician on 4/15/25. Physician's documentation was provided showing that Individual #1's psychiatry appointment that was scheduled for 6/10/25, had been cancelled by the agency due to the elevator in Individual #1's apartment building being inoperable. Although, the agency did not provide documentation from the physician showing that another medication review appointment had been promptly rescheduled. Moreover, Individual #1's physician sent a facsimile to the agency on 7/15/25 at 11:10 AM that read: "[Individual #1 is due to see [Physician #2]. Please call to schedule." [Repeated Violation-7/30/24 et al.] | 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. | The individual was scheduled for a psychiatric medication review with their physician on [8/5/25].
Documentation of the review, including the reason for continuing, dosage, and any necessary updates, was obtained and added to the individual's record.
A copy of the documentation will be sent to the department |
09/01/2025
| Implemented |
| 6400.166(b) | The blister pack for Individual #1's prescribed pro re nata medication, Hydroxyz Pam Cap. 25 MG---Take 1 capsule by mouth three times a day as needed for increased agitation/ anxiousness---revealed that one capsule had been depressed from the pill bubble. The staff who had given the capsule did not write their initials or date on the blister pack. The medication label on the blister pack showed that this mediation had been dispensed from the pharmacy on 4/1/25. However, Individual #1's April, May, June, and July 2025 Medication Administration Records in Therap were not initialed, documenting the administration of this medication. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | - The staff responsible was retrained on the requirement to document MAR entries at the time of administration.
- The Nurse Coordinator reviewed the Individual's MAR to ensure no further late entries occurred. |
09/01/2025
| Implemented |
| 6400.182(c) | Individual #1's Service Plan, last updated 7/16/25, contained the following discrepancies between their initial and current assessment, completed on 3/28/25, in the following health and safety skill domains: regarding poisonous materials, Individual #1's Service Plan, last updated 7/16/25, stated that "[Individual #1] is not at risk for ingesting any non-food items or poisons. "[Individual #1] would not require supervision in this area." However, Individual #1's assessment, completed on 3/28/25, indicated that Individual #1 is able to safely use poisonous substances, but chooses not to. [Repeated Violation-7/30/24 et al.] | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The Program Specialist will review all Individual Support Plans to ensure they accurately reflect the information from the most current assessment. Any discrepancies identified between the assessment and the ISP will be communicated to the individuals Supports Coordinator to ensure the plan is promptly updated. |
09/01/2025
| Implemented |