| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.110(a) | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. The smoke detector located in the basement was not operable when tested at the time of the inspection. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | A new smoke detector was installed on 8/26/25. |
08/26/2025
| Implemented |
| 6400.141(a) | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Individual #1 was admitted on 3/11/2025 and their most recent physical examination was completed on 8/15/2024. The individual has not had another physical examination and is not scheduled for a physical examination until 9/05/2025. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The physical examination for individual #1 was completed. |
09/01/2025
| Implemented |
| 6400.181(a) | Individual #1 did not have an initial assessment completed with 60 days of the date of admission. The individual was admitted on 3/11/2025 and the initial assessment was not completed until 6/09/2025. | 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. | This violation was reviewed and discussed during the post-inspection meeting. Chapter 6400.181(a) was reviewed. |
08/29/2025
| Implemented |
| 6400.181(e)(10) | The initial assessment completed on 6/09/2025 for Individual #1 did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | Annual Assessment for individual #2 was completed. |
09/05/2025
| Implemented |
| 6400.214(a) | A copy of the current assessment for Individual #1 was not in the home at the time of inspection. | Record information required in § 6400.213(1) (relating to content of records) shall be kept at the home. | Copy of individual #1's current assessment was printed and a copy placed at the home. |
08/27/2025
| Implemented |
| 6400.216(a) | Individuals' files containing personal identification and protected health information was found stored in cardboard boxes in an unlocked area of the basement. | An individual's records shall be kept locked when unattended.
| A lockable door was installed at the storage location mentioned above. |
08/29/2025
| Implemented |
| 6400.51(a)(1) | Direct service workers shall complete 24 hours of training relating to job skills and knowledge each year. Staff #2 did not complete 24 hours of training during the training year 7/01/2024 through 6/30/2025. The staff completed 16 hours of training during the training year reviewed. | Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Management, program, administrative and fiscal staff persons. | Staff #2 has been scheduled for all the upcoming mandatory and additional trainings |
08/29/2025
| Implemented |
| 6400.51(a)(3) | Prior to working alone with individuals and within 30 days of hire, direct service workers including full and part-time staff persons shall complete the orientation trainings described in 6400.51b. Staff #1 was hired on 3/28/2025 but did not complete all of the required orientation trainings within 30 days of hire. Staff #1 did not complete orientation training in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships until 5/30/2025. | Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Direct service workers, including full-time and part-time staff persons. | This violation was discussed during the post-inspection meeting where the orientation schedule and Chapter 6400.51(a)(3) were reviewed. Staff #1 has been scheduled for the mandatory and additional trainings for this fiscal year. |
08/29/2025
| Implemented |
| 6400.52(c)(5) | Staff #2 works directly with individuals and did not complete the required annual training in the safe and appropriate use of behavior supports during training year 7/01/2024 through 6/30/2025. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | Staff #2 completed the Safe and Appropriate use of Behavior Supports training on 8/29/25. |
08/29/2025
| Implemented |
| 6400.165(f) | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs (SEEN plan) of the individual related to the symptoms of the psychiatric illness. Individual #1 is prescribed medication to treat the symptoms of a diagnosed psychiatric illness and there was not a SEEN plan in the individual's record.
The individual did have a behavioral support plan prior to admission to the current provider but there was not a copy of the plan in the individual's record or if the plan is still current. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | A new copy of individual #1's BSP was printed and placed in the home on 8/26/25. |
09/01/2025
| Implemented |
| 6400.165(g) | The psychiatric medication review that occurred on 7/17/2025 did not include documentation of the reason for prescribing medications and the necessary dosages. | 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. | A copy of individual #1's MAR was attached to the completed 7/17/25 psyc visit form. |
08/29/2025
| Implemented |