| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(4) | Individual #1's, date of admission 5/03/2025, physical examination, completed 2/10/2025, did not include a hearing screening. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | KACS CEO and KACS program specialist will review all admission documents to ensure that all required information is current, up to date, and accurate. |
02/06/2026
| Implemented |
| 6400.141(c)(11) | Individual #1's physical examination completed 2/10/2025 did not include an assessment of the individual's health maintenance needs and the need for blood work at recommended intervals. It was left blank. | 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. | KACS program specialist will review all consulatation forms and physical paperwork yo ensure after appointments summary with all informationis completed in totality before being filed. |
02/06/2026
| Implemented |
| 6400.181(e)(8) | Individual #1's assessment, completed 6/13/2025, documents the individual is capable of independently evacuating the apartment although he would require verbal direction and supervision to do so. On 12/08/2025 Chief Executive Officer #1 confirmed Individual #1 evacuates independently. Individual #2's assessment, completed 8/22/2025, documents the individual is capable of independently evacuating the apartment although she would require verbal direction and supervision to do so. On 12/08/2025 Chief Executive Officer #1 confirmed Individual #2 evacuates independently. | The assessment must include the following information: The individual's ability to evacuate in the event of a fire. | KACS program specialist will update individual #1's assessment to address their ability to evacuate; KACS CEO will review the assesment to enure the proper corrections have been made. |
02/06/2026
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's assessment completed 6/13/2025 documents Individual #1 has a representative payee that is in charge of his money because he is unable to manage money on his own. Individual #1's individual support plan, last updated 6/17/2025, documents "[Individual #1] needs assistance in budgeting, paying bills, and overall financial management." On 12/18/2025 Chief Executive Officer #1 confirmed Individual #1 is independent in managing his weekly spending money, provided by the representative payee. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| KACS program specialist will update individuals current assesment to address their level of finacial independence. |
02/06/2026
| Implemented |
| 6400.34(a) | Individual #2's, date of admission 7/25/2025, was initially informed of individual rights 8/06/2025. [Repeated violation: 2/06/2025] | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | KACS program specialist will inform the individual of thier rights prior to admission date, and possibly during trasition visits to ensure they are informed before they are in the home. |
02/06/2026
| Implemented |
| 6400.182(c) | Individual #1's individual support plan, last updated 6/17/2025, documents "[Individual #1] has a bed shaker that is linked to the fire alarm system should he need to be awaken in the event of a fire. He may become nervous or upset in the event of an emergency and require some form of direction. Over [the individual] is ambulatory. However, others should remember that he may not be able to be as quick on his feet as necessary due to his [diagnosis]. [The individual] would require physical assistance to exit the building due to his [diagnosis] and unable to climb stairs independently." On 12/08/2025 Chief Executive Officer #1 confirmed Individual #1 evacuates independently. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | KACS management team will discuss with individuals team and the individual to discuss if the bed shaker is currently needed and update the home and assessment according to meeting outcome. |
02/06/2026
| Implemented |