| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The home's self-assessment, completed on 11/25/24, was not conducted either within 3-6 months of the current license's expiration date of 2/22/2025 or within 6-9 months following the last annual inspection by the Department completed 12/20/23. [Repeated Violation-12/19/23, et al] | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| A compliance calendar has been implemented to ensure timely completion of the annual self-assessment. Management was trained regarding the requirements for completing and documenting the annual self-assessment. |
02/27/2025
| Implemented |
| 6400.64(a) | On 12/6/24 at 10:57 AM, the air fryer in the kitchen contained a film of grease and food remnants. At 11:00 AM, there was a sticky-paper fly trap hanging from the ceiling in kitchen with deceased insects attached. At 11:02 AM, the first-floor hallway bathroom had a light fixture on the ceiling that was filled with a thick coating of dirt and debris. [Repeated Violation-1/19/23 et al and 12/19/23, et al] | Clean and sanitary conditions shall be maintained in the home. | Staff were retrained on sanitation policies. |
02/27/2025
| Not Implemented |
| 6400.64(f) | On 12/6/24 at 10:57 AM, the rear deck of the home contained three trash receptacles that were overflowing with garbage and did not have lids. [Repeated Violation-1/19/23 et al and 12/19/23, et al] | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | Management ordered new trash cans with lids for the home. |
02/27/2025
| Implemented |
| 6400.66 | On 12/6/24 at 11:26 AM, the front egress of the home did not have a source of lighting. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Management contacted maintenance to address the lighting in the front egress. |
02/27/2025
| Not Implemented |
| 6400.67(a) | On 12/6/24 at 11:10 AM, the paint on the ceiling in the shower stall of the home's second-floor bathroom was peeling in multiple areas. [Repeated Violation-12/19/23, et al] | Floors, walls, ceilings and other surfaces shall be in good repair. | Management contacted the contracted maintenance provider to assess any damage in the shower stall and repaint. |
02/27/2025
| Not Implemented |
| 6400.67(b) | On 12/6/24 at 11:18 AM, there was an exposed drain hole in the basement that did not contain a drain cover posing a potential tripping hazard. At 11:08 AM, the airduct vent cover in the home's second-floor bathroom was detached approximately two inches from the wall leaving sharp corners protruding out. On 12/6/24 at 11:04 AM, the dryer's lint trap filter was covered in a thick coating of lint, dust, and particles. [Repeated Violation-1/19/23 et al and 12/19/23, et al] | Floors, walls, ceilings and other surfaces shall be free of hazards. | Management and staff were retrained on the responsibility of keeping the home free of hazards. The Program Specialist posted a sign stating the lint trap is to be cleaned after every use. |
02/27/2025
| Not Implemented |
| 6400.71 | On 12/6/24 at 11:01 AM, emergency numbers were not posted on or near the phone on the first floor of the home. | 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.
| Management made new copies of the emergency numbers and placed them on the downstairs phone. |
02/27/2025
| Not Implemented |
| 6400.73(a) | On 12/6/24 at 11:19 AM, the stairwell that leads from the first floor to the basement of the home has five steps that stop at a landing where there is an egress point to the outside of the home. This set of five steps did not contain a railing. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | Management contacted maintenance to install a railing to the basement stairs. |
02/27/2025
| Implemented |
| 6400.104 | The local fire department notification letter dated 4/19/24 for this home indicates that Individual #1 requires physical assistance to evacuate in the event of an actual fire, but it does not include a description or diagram of the exact location of their bedroom. | 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.
| Management sent a formal written notification to the local fire department, including the home's address and a detailed floor plan indicating the exact locations of bedrooms for the individual requiring evacuation assistance. Staff were trained on the importance of maintaining current evacuation information and the proceedure for updating the fire department. |
02/27/2025
| Implemented |
| 6400.141(b) | Individual #1's most recent physical examination completed on 7/8/24, was not signed and dated by a 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. | Management was retrained on the elements of proper individual file documentation. |
02/27/2025
| Implemented |
| 6400.141(c)(1) | Individual #1's most recent physical examination completed on 7/8/24, did not include a previous review of their medical history. | The physical examination shall include: A review of previous medical history. | Management was retrained on the elements of proper individual physical documentation requirements. |
02/27/2025
| Not Implemented |
| 6400.141(c)(3) | Individual #1's date-of-birth is 1/8/98. Their most recent physical examination completed on 7/8/24, did not address immunizations or include a separate attached list. | 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. | Management contacted the individual's PCP to get a list of immunizations. |
02/27/2025
| Not Implemented |
| 6400.141(c)(14) | Individual #1's physical examination completed on 7/8/24, did not include 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. | Management was retrained on the proper elements of a individual physical form. |
02/27/2025
| Not Implemented |
| 6400.141(c)(15) | Individual #1's physical examination completed on 7/8/24, did not address special instructions for their diet. This field was left blank. | The physical examination shall include:Special instructions for the individual's diet. | Management was retrained on the elements of an individual's physical exam documentation. |
02/27/2025
| Not Implemented |
| 6400.195(a) | On 12/6/24 at 11:16 AM, the knives were discovered locked in a basement closet. Program Director/ Chief Executive Officer Designee #1 stated that at this time there is currently no restrictive procedure plan in place. In the "Know and Do" section of Individual #1's individual plan last updated on 11/25/24, it reads, "[Individual #1] has a restrictive plan for sharps, butter knives, blender blades, pen, pen caps, peelers, skewers, can openers, and razors. This plan was renewed on 9/1/23," but not thereafter. | 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. | Management contacted the BSP in order to obtain a written restrictive procedure plan that complies with regulatory requirements and includes necessary safeguards. A review process was implemented to ensure that all restrictive procedures are included in written plans before being used. Staff will be trained annually on the proper use of restrictive procedures and the requirement of a written plan. |
02/25/2025
| Not Implemented |