| 6400.15(a) | The self-assessment developed 9/08/2025 was not completed entirely. The following regulations were left blank: 6400.44b1 through and including 6400.52c6, 6400.61a, 6400.61b, 6400.77b, and 6400.77c. | 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.
| Provider will ensure that self-inspections are completed in accordance with the 6400.15. Program Supervisors were retrained on 6400.15 and the licensing inspection instrument utilized during self-inspections. Program Manager will review all self-assessments to ensure that each area has been assessed and corrections have been made. Results will be tracked by site for agency purpose. |
04/02/2026
| Implemented |
| 6400.182(c) | Individual #1's assessment completed 11/01/2025 documents the individual can never be outside of eyesight supervision while in the community. Individual #1's individual support plan, last updated 2/19/2026, documents [Individual #1] is not to be alone in the community. [Individual #1] needs to have someone within arms' reach as [they] may dart into traffic. Staff also need to be aware of [Individual #1]'s triggers and remove [them] from the environment if necessary to avoid [them] engaging in aggression towards [themselves] or others. [Repeat Violation, 3/18/2025, et. al.). | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Provider analyzed the current assessment and determined the supervision section could be ambiguous. Provider developed a new assessment that included all of the required regulatory elements and provided additional clarity and details to ensure the information between the ISP and assessment is in alignment. |
04/01/2026
| Implemented |