| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.111(c) | The kitchen fire extinguisher had a rating of 1-A:10-B:C instead of a minimum of 2A-10BC rating. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | Upon notification of the finding, the kitchen fire extinguisher was replaced with a fire extinguisher rated 2A-10BC. The extinguisher was inspected and tagged to confirm it met the required rating and was properly charged and accessible.
Fire extinguishers in all other locations of the home were inspected on the same date to confirm each met or exceeded the minimum required rating for its location. No additional deficiencies were identified.
Responsible person: House Manager |
04/10/2026
| Implemented |
| 6400.141(c)(3) | The 04/03/26 annual physical for individual #1 did not discuss immunizations except for a Tetanus shot. | 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. | Upon notification of the finding, the physician's office was contacted to obtain a complete immunization review as recommended by the U.S. Public Health Service/CDC for Individual #1. The updated documentation was placed in Individual #1's record.
Physical examination records for all other individuals in the home were reviewed on the same date to confirm immunization status was fully addressed. No additional deficiencies were identified.
Responsible person: House Manager |
04/10/2026
| Implemented |
| 6400.141(c)(13) | The 04/03/26 annual physical exam for individual #1 did not discuss any contraindicated medications. | The physical examination shall include: Allergies or contraindicated medications. | Upon notification of the finding, the physician's office was contacted to obtain documentation addressing allergies and contraindicated medications for Individual #1. The updated documentation was placed in Individual #1's record.
Physical examination records for all other individuals in the home were reviewed on the same date to confirm allergies/contraindicated medications were addressed. No additional deficiencies were identified.
Responsible person: House Manager |
04/10/2026
| Implemented |
| 6400.181(e)(13)(i) | The 01/17/26 annual assessment for individual #1 did not discuss the individual's progress over the last 365 calendar days. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| Upon notification of the finding, the assessment for Individual #1 was revised to include the individual's progress over the preceding 365 calendar days in the area of health, based on a review of the individual's health records for that period. The corrected assessment was placed in Individual #1's record and distributed to the individual's team as applicable.
Annual assessments for all other individuals in the home were reviewed on the same date to confirm the 365-day progress component was addressed for all required areas. No additional deficiencies were identified. |
04/10/2026
| Implemented |
| 6400.15(b) | Self-assessments for all homes were done using the 6500 Life Sharing Inspection Record form instead of the 6400 Community Homes form. | (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. | April 10, 2026 -- Upon notification of the finding, the agency identified that self-assessments had been conducted using the incorrect licensing instrument (6500 Life Sharing) rather than the 6400 Community Homes instrument required for this program type. The agency obtained the correct 6400 self-assessment instrument and re-conducted the self-assessment for this home using the correct form.
The agency reviewed self-assessment records for all other 6400-licensed homes to confirm the correct instrument is identified and available for use going forward.
Responsible person: Agency Program Specialist |
04/10/2026
| Implemented |
| 6400.165(g) | The last psychiatric medication review for individual #1 was done on 12/18/25 which is over the review period of at least every 3 months. | 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. | Upon notification of the finding, Individual #1's prescribing physician was contacted to schedule an immediate psychiatric medication review. The review was completed and documented, including the reason for prescribing the medication, the need to continue the medication, and the necessary dosage.
Psychiatric medication review due dates for all other individuals in the home were reviewed on the same date to confirm no other reviews were overdue. No additional deficiencies were identified.
Responsible person: House Manager |
04/10/2026
| Implemented |
| 6400.195(a) | The behavior support component of the individual plan does not address any active restrictive procedures for individual #1; however, the HRT team meetings of 10/15/25 and 04/16/25 give restrictive procedures of plexiglass covering the individual's television and a plexiglass barrier between the individual and a vehicle driver where the individual is a passenger | For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures. | Upon notification of the finding, the Program Specialist convened Individual #1's team to update the behavior support component of the individual plan to formally document both restrictive procedures currently in use --- the plexiglass television covering and the vehicle plexiglass barrier --- including the rationale for each procedure, the specific behavior(s) each is intended to address, and the required human rights team review and approval in accordance with § 6400.194.
Both restrictive procedures were confirmed to have been reviewed by the human rights team as reflected in the 10/15/25 and 04/16/25 HRT meeting records; this review and approval was cross-referenced and incorporated into the updated behavior support component.
Individual plans and HRT records for all other individuals in the home were reviewed on the same date to confirm that any restrictive procedures in use were consistently reflected in each individual's behavior support component. No additional deficiencies were identified. |
04/10/2026
| Implemented |