| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | On 1/21/2026 at 11:05AM, an unknown purple substance in an unlabeled, plastic spray bottle under the sink in the kitchen of the home. | Poisonous materials shall be stored in their original, labeled containers. | The unlabeled bottle marked "Pine" has been removed 1/21/2026. Staff will be retrained to use properly labeled containers, all poisonous material shall be stored in their original and labeled containers. Staff will dispose of any unlabeled containers immediately
upon discovery and report to the site supervisor of discovery moving forward. |
02/19/2026
| Implemented |
| 6400.64(a) | On 1/21/2026 at 11:08AM, there was a thick layer of grease and burnt food chards on the bottom and the interior door of the oven in the kitchen of the home. | Clean and sanitary conditions shall be maintained in the home. | The inside of the oven will has been cleaned 1/21/2026 and is free of debris and chards. Staff will be retrained to clean the oven and stove after each use. Site supervisor will monitor randomly and weekly on the weekly site inspection log. |
02/22/2026
| Implemented |
| 6400.64(f) | On 1/21/2026 at 11:04AM, there were four trash receptacles with no lid containing plastic bags of miscellaneous trash items near the fence in the back of the home. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | All trash can lids have been closed 1/21/2026. New garbage cans will be purchased for excess garbage. Staff will be retrained to ensure that all cans are closed tightly to prevent rodents and insects. Staff will report the need for additional garbage cans immediately to the site supervisor or the house manager. |
02/22/2026
| Implemented |
| 6400.65 | On 1/21/2026 at 11:19AM, there was a one-quarter-inch thick layer of dust covering the ventilation fan in the ceiling of the bathroom on the second floor of the home. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| The fan in the bathroom has been cleansed of the dust covering 1/21/2026. Staff will be retrained on the need to maintain a clean and sanitary home to include the vents and fans of the homes. Site supervisor/ site manager will monitor weekly for compliance on weekly inspection log. |
02/22/2026
| Implemented |
| 6400.67(a) | On 1/21/2026 at 11:12AM, large areas of paint on the walls and floor were cracked and peeling in the basement of the home. | Floors, walls, ceilings and other surfaces shall be in good repair. | Peelings on the floor and wall will be immediately cleaned of old and chipped paint. Picture of the repair will be sent as part of the POC. Staff will be retrained to report any surfaces that are not in good repair to include floors, ceilings and walls in the basement or any other part of the home. |
02/22/2026
| Implemented |
| 6400.67(b) | On 1/21/2026 at 11:12AM, the metal drain cover was broken with a rusted piece lying beside it and an eight-inch by six-inch area of the floor next to it was cracked and broken in the basement of the home posing a tripping hazard. At 11:16AM, the landing at the top of the interior stairs leading to the basement of the home is weathered and peeling with broken duct tape on top of it posing a tripping hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Metal drain will be repaired immediately. The metal drain will be covered to insure that there is not a tripping hazard until the repair. Picture of the repair will be submitted for POC, Site supervisor will monitor weekly for any surfaces in disrepair and report to administration for immediate repair. |
02/22/2026
| Implemented |
| 6400.72(b) | On 1/21/2026 at 11:22AM, the bottom right corner of the screen was detached and protruding approximately one-in-a-half inches from the window in Individual #2's bedroom on the second floor of the home. | Screens, windows and doors shall be in good repair. | Screen in the window to be replaced or repaired immediately, 1/21/2026. Staff will be instructed report any ripped or screens needing replaced to the site supervisor or house manager. Staff will be retrained to emphasis the importance of screens and windows being in good repair. Copy of training to be submitted as part of the POC. |
02/22/2026
| Implemented |
| 6400.74 | On 1/21/2026 at 11:16AM, there was no nonskid surface on the twelve interior stairs leading to the basement of the home. | Interior stairs and outside steps shall have a nonskid surface.
| Non skid surface will be applied to the twelve stairs leading the to the basement of the home completed 1/21/2026. A picture of the repair will be submitted as part of the POC. Site supervisor/house manager will conduc |
02/22/2026
| Implemented |
| 6400.110(e) | On 1/21/2026 at 11:26AM, the smoke alarm in the attic was not interconnected with the smoke alarms on the first floor and the basement of the home. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | Fire alarms will be inspected for interconnection and replaced if needed. All interconnected fire alarms not working properly will be replaced immediately. Monthly fire drill will continue as required. Staff will be retrained to report any malfunctioning fire alarms, including interconnection issues or beeping alarms that may need new batteries (if applicable) to the house manager immediately for replacement. |
02/22/2026
| Implemented |
| 6400.181(a) | Individual #1's most current assessment, completed by Program Specialist #1, was not dated. The assessment only indicated that it was completed in 2025; therefore, compliance with this regulation could not be measured. [Repeat Violation, 1/30/2026] | 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. | Assessment will be signed and dated upon completion. Program specialist will review assessment to ensure that the date and signature are completed on the assessment. Completed and dated signed assessment will be submitted for the POC. |
02/22/2026
| Implemented |
| 6400.181(d) | Individual #1's most current assessment, completed in 2025, was not dated by Program Specialist #1. | The program specialist shall sign and date the assessment. | Assessment will be signed and dated upon completion. Program specialist will review assessment to ensure that the date and signature are completed on the assessment. Completed and dated signed assessment will be submitted for the POC |
02/22/2026
| Implemented |
| 6400.181(e)(1) | Individual #1's most current undated assessment, completed in 2025 by Program Specialist #1, did not include an assessment of the individual's functional strengths and needs. These assessment areas were omitted entirely from the agency's assessment form. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | Assessment paperwork will be immediately corrected and completed to include the functional strengths of the individual. Completed assessment will be submitted for the POC. Revised and corrected assessment will be submitted for the POC. Original assessment paperwork was revised. The needed sections were omitted accidentally. |
02/22/2026
| Implemented |
| 6400.181(e)(2) | Individual #1's most current undated assessment, completed in 2025 by Program Specialist #1, did not include an inventory of the individual's interests. This assessment area was omitted entirely from the agency's assessment form. | The assessment must include the following information: The likes, dislikes and interest of the individual. | Assessment paperwork will be immediately corrected and completed to include the likes, dislikes, and the interests of the individual. Completed assessment will be submitted for the POC. Revised and corrected assessment will be submitted for the POC. Original assessment paperwork was revised. The needed sections were omitted accidentally. |
02/22/2026
| Implemented |
| 6400.32(h) | On 1/21/2026 at 11:10AM, there were cameras in the living room and dining room of the home. Staff interviews revealed that the cameras have video and audio recording. | An individual has the right to privacy of person and possessions. | The camera in the living room and dining room of the home have been disconnected and removed as of 1/22/2026 by the house manager. There will be no further use of cameras in the common areas of the home due to privacy rights of the individuals in the home. |
02/22/2026
| Implemented |
| 6400.166(a)(11) | Individual #1's January 2026 Medication Administration Record did not include the diagnosis or purpose for Advair Diskus, Aldactone, Celexa, Diovan, Ferrous Sulfate, Jardiance, Sodium Chloride and Vitamin B-12. [Repeat Violation, 1/30/2025] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Individual 1 MAR has been immediately corrected to include the diagnosis. Company nurse will review all MARs before the month of Medication administration to ensure that all MARS are complete and accurate to include the diagnose or purpose for the medication. Staff will be retrained to emphasize that the diagnosis for each medication should be on the MAR before administering the
medication. Record of training will be included for the POC. |
02/22/2026
| Implemented |
| 6400.166(a)(13) | Individual #1's January 2026 Medication Administration Record did not include the full name of the Direct Service Workers that administered the medications. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | Staff will be retrained to emphasize that their name and initial should be on the back of the MAR before administering medication. Record of training will be included for the POC. Ste supervisor/House manager will monitor MARs weekly to ensure that the signatures are on the back of the MAR |
02/22/2026
| Implemented |
| 6400.181(f) | Individual #1's most current undated assessment, completed in 2025 by Program Specialist #1, was not provided to the individual plan team members at least 30 calendar days prior to the individual plan meeting that occurred on 9/9/2025. [Repeat Violation, 1/30/2025] | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Program specialist will ensure that the ISP team receives the assessment 30 days before the isp. Assessment will be emailed to all of the isp team. A copy of the email will be printed and place in the individual record. Date and time of email will be placed on the assessment for reference. |
02/22/2026
| Implemented |
| 6400.182(c) | Individual #1's most current undated assessment, completed in 2025 by Program Specialist #1, indicated that Individual #1 was unable to safely use and avoid poisonous substances. Individual #1's support plan, last updated 10/17/2025, indicated that "[Individual #1] understands the dangers associated with poisonous household items and would not knowingly or unknowingly ingest them is they were left unattended." Individual #1's most current undated assessment, completed in 2025 by Program Specialist #1, indicated that Individual #1 was unable to understand the danger of heat sources and sense and move away quickly from heat sources which exceed 120° F. Individual #1's support plan, last updated 10/17/2025, indicated that "[Individual #1] recognizes heat sources and independently avoids them." ) Individual #1's most current undated assessment, completed in 2025 by Program Specialist #1, indicated that Individual #1 required total assistance to evacuate in the event of a fire. Individual #1's support plan, last updated 10/17/2025, indicated that "At home, [Individual #1] requires verbal prompts to evacuate the premises." Individual #1's support plan has not been revised based upon the current assessment. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Individual #1 assessment has been corrected to include that the individual understands the dangers of poisonous materials, recognizes heat sources and only needs verbal prompts to evacuate the premises. Program specialist will use the individual isp to reference when doing the assessment to ensure that the information on the assessment is consistent with the isp. |
02/22/2026
| Implemented |