| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.63(a) | At 10:05AM, the hot water temperature measured 133.1F at the sink in the kitchen of the home. | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | Training will be held on Friday, August 1, 2025. During this session, you will learn how to properly complete the digital Water Temperature Log. This form is crucial for maintaining health and safety standards and must be completed by staff at the start of each shift. You will need to record the temperatures for the kitchen sink, bathroom sink, and bathroom shower/tub. |
08/08/2025
| Not Implemented |
| 6400.64(a) | At 10:15AM, the ceiling in the vacant bedroom had splattering of various size brown spots. At 10:05AM, the coffee carafe in the coffee machine contained dried coffee grinds hardened to the inside. At 10:08AM, the stove top burners and drip pans were heavily soiled with what appears to be burnt food debris and grease. At 10:12AM, the inside of the bathtub on the first floor of the home was discolored with what appears dirt and soap scum. Along the wall and the bathtub in the bathroom on the first floor of the home, there dark black substance that appears to be mildew and/or mold. At 10:52AM, in individual #1's bedroom, there were multiple dark, sticky spots, food crumbs and other debris throughout the laminate wood panel floor and on top of the dresser; and a brownish, three-inch by four-inch splatter on the white baseboard on the right side of Individual #1's bed. | Clean and sanitary conditions shall be maintained in the home. | There are two levels of supervision for implementation and oversight, including all items in the OCS Daily task Checklist: This Work Order Form is used to document, track, and complete essential site-related tasks across all On-Site Companionship Services, Inc. locations. It ensures that maintenance, cleaning, staffing, care support, and supply management are consistently performed and reviewed on a regular basis.
Purpose:
To help site managers and team leads stay on top of daily operations, identify any concerns promptly, and maintain a safe, clean, and well-staffed environment for both clients and staff. The team leads will also do weekly room checks to ensure personal areas are maintained according to 6400.64 (a) |
08/08/2025
| Not Implemented |
| 6400.64(f) | At 10:02AM, the two exterior trash receptacles next to the porch in the front of the home were not able to be closed due to protruding discarded boxes and other discarded items. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | There are two levels of supervision for implementation and oversight, including all items in the OCS Daily task Checklist: This Work Order Form is used to document, track, and complete essential site-related tasks across all On-Site Companionship Services, Inc. locations. It ensures that maintenance, cleaning, staffing, care support, and supply management are consistently performed and reviewed on a regular basis.
Purpose:
To help site managers and team leads stay on top of daily operations, identify any concerns promptly, and maintain a safe, clean, and well-staffed environment for both clients and staff. The team leads will also do weekly room checks to ensure personal areas are maintained according to 6400.64 (a) Team leads will post the Trash Schedule in the sites to ensure the receptacles are emptied on a regular schedule. |
08/08/2025
| Not Implemented |
| 6400.67(a) | At 10:13AM, the one of the three metal slats in the mechanical vent in the hallway ceiling was bent downward exposing an opening in the ceiling. | Floors, walls, ceilings and other surfaces shall be in good repair. | There are two levels of supervision for implementation and oversight, including all items in the OCS Maintenance Checklist: This Work Order Form is used to document, track, and complete essential site-related tasks across all On-Site Companionship Services, Inc. locations. It ensures that maintenance, cleaning, staffing, care support, and supply management are consistently performed and reviewed on a regular basis.
Purpose:
To help site managers and team leads stay on top of daily operations, identify any concerns promptly, and maintain a safe, clean, and well-staffed environment for both clients and staff. The team leads will also do site checks to ensure personal areas are maintained according to 6400.67 (a) Team leads will post the maintenance request form in the sites to ensure the proper reporting of maintenance issues. |
08/08/2025
| Not Implemented |
| 6400.67(a) | At 10:52AM, the curtain rod over top of the window facing the front of the home in Individual #1's bedroom was bent downward approximately four inches preventing the hanging curtain to cover the entire opening of the window. | Floors, walls, ceilings and other surfaces shall be in good repair. | There are two levels of supervision for implementation and oversight, including all items in the OCS Daily task Checklist and Maintenance Checklist: This Work Order Form is used to document, track, and complete essential site-related tasks across all On-Site Companionship Services, Inc. locations. It ensures that maintenance, cleaning, staffing, care support, and supply management are consistently performed and reviewed on a regular basis.
Purpose:
To help site managers and team leads stay on top of daily operations, identify any concerns promptly, and maintain a safe, clean, and well-staffed environment for both clients and staff. The team leads will also do weekly site walk throughs to ensure personal areas are maintained according to 6400.67 (a) Team leads will post the maintenance request form in the sites to ensure the proper reporting of maintenance issues. |
08/08/2025
| Not Implemented |
| 6400.68(b) | At 10:13AM, the hot water temperature measured 132.2F at the bathtub in the bathroom on the first floor of the home. [Repeated Violation 2/25/25 et al] | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Training will be held on Friday, August 1, 2025. During this session, you will learn how to properly complete the digital Water Temperature Log. This form is crucial for maintaining health and safety standards and must be completed by staff at the start of each shift. You will need to record the temperatures for the kitchen sink, bathroom sink, and bathroom shower/tub. |
08/08/2025
| Not Implemented |
| 6400.72(a) | At 10:09AM, there was no screen in the kitchen window. At 10:41AM there was no screen in the living room window facing the front of the home. [Repeated Violation 2/25/25 et al] | Windows, including windows in doors, shall be securely screened when windows or doors are open. | There are two levels of supervision for implementation and oversight, including all items in the OCS Daily task Checklist and Maintenance Checklist: This Work Order Form is used to document, track, the sizes and variations of windows and screens for each home across all On-Site Companionship Services, Inc. locations. It ensures that maintenance, cleaning, staffing, care support, and supply management are consistently performed and reviewed on a regular basis.
Purpose:
To help site managers and team leads stay on top of daily operations, identify any concerns promptly, and maintain a safe, clean, and well-staffed environment for both clients and staff. The team leads will also do weekly site walk throughs to ensure personal areas are maintained according to 6400.72 (a) Team leads will post the maintenance request form in the sites to ensure the proper reporting of maintenance issues. |
08/08/2025
| Not Implemented |
| 6400.72(b) | At 10:17AM, the vinyl plastic window casing on the exterior right side of the window frame in the staff office was broke in two places. [Repeated Violation 2/25/25 et al] | Screens, windows and doors shall be in good repair. | There are two levels of supervision for implementation and oversight, including all items in the OCS Daily task Checklist and Maintenance Checklist: This Work Order Form is used to document, track, the sizes and variations of windows and screens for each home across all On-Site Companionship Services, Inc. locations. It ensures that maintenance, cleaning, staffing, care support, and supply management are consistently performed and reviewed on a regular basis.
Purpose:
To help site managers and team leads stay on top of daily operations, identify any concerns promptly, and maintain a safe, clean, and well-staffed environment for both clients and staff. The team leads will also do weekly site walk throughs to ensure personal areas are maintained according to 6400.72 (b) Team leads will post the maintenance request form in the sites to ensure the proper reporting of maintenance issues. |
09/01/2025
| Not Implemented |
| 6400.81(i) | At 10:53AM, Individual #1's bedroom window facing the side of the home did not have drapes, curtains, shades, blinds or shutters. | Bedroom windows shall have drapes, curtains, shades, blinds or shutters. | There are two levels of supervision for implementation and oversight, including all items in the OCS Daily task Checklist and Maintenance Checklist: This Work Order Form is used to document, track, the sizes and variations of windows and screens for each home across all On-Site Companionship Services, Inc. It ensures that maintenance, cleaning, staffing, care support, and supply management are consistently performed and reviewed on a regular basis.
Purpose:
To help site managers and team leads stay on top of daily operations, identify any concerns promptly, and maintain a safe, clean, and well-staffed environment for both clients and staff. The team leads will also do weekly room checks to ensure personal areas are maintained according to 6400.81 (i) |
08/08/2025
| Not Implemented |
| 6400.81(k)(3) | At 10:52AM, Individual #1's bed did not have pillows, sheets or a mattress cover. | In bedrooms, each individual shall have the following: Bedding, including pillow, linens and blankets appropriate for the season. | [The agency does not currently support individuals in community homes. (DPOC by AES,HSLS on 6/3/2026)] |
06/03/2026
| Not Implemented |
| 6400.110(a) | At 10:43AM, the smoke detector located in the basement was not operable. At 10:49AM, there were no smoke detectors on the first floor of the home. [Repeated Violation - 5/1/25] | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | Hardwire Installation vs battery operation for the smoke detectors on each level |
09/01/2025
| Not Implemented |
| 6400.114(b) | At 10:53AM, an ashtray with three partially smoked rolled cigarettes along with other smoking paraphernalia to include but not limited to a pipe, a vaping device, a small plastic bag, a small tray, a scissor/tweezer device were on the comforter of Individual #1's bed where Individual #1 was sleeping. The home's smoking policy states that staff or visitors are to dispose of all cigarette butts in a receptacle with a lid. [Repeated Violation 2/25/25 et al] | Written smoking safety procedures shall be followed. | There are two levels of supervision for implementation and oversight, including all items in the OCS Daily task Checklist: This Work Order Form is used to document, track, and complete essential site-related tasks across all On-Site Companionship Services, Inc. locations. It ensures that maintenance, cleaning, staffing, care support, and supply management are consistently performed and reviewed on a regular basis.
Purpose:
To help site managers and team leads stay on top of daily operations, identify any concerns promptly, and maintain a safe, clean, and well-staffed environment for both clients and staff. The team leads will also do weekly room checks to ensure personal areas are maintained according to 6400.114 (b) |
06/03/2026
| Not Implemented |
| 6400.171 | At 10:04AM, an uncovered metal cooking pot containing used cooking oil was atop the stove in the kitchen of the home. According to the FDA's safe storage recommendations, used cooking oil should be strained, stored in an airtight container, and refrigerated for reuse. [Repeated Violation - 2/25/25, et al and 5/1/25] | Food shall be protected from contamination while being stored, prepared, transported and served.
| [The agency does not currently support individuals in community homes. (AES, HSLS on 6/3/2026)] |
06/03/2026
| Not Implemented |
| 6400.214(a) | At 10:20AM, Individual #1's personal information sheet was not kept in the home. Staff interviews revealed that Individual #1's records are at the office. [Repeated Violation 5/1/25] | Record information required in § 6400.213(1) (relating to content of records) shall be kept at the home. | [The agency does not currently support individuals in community homes. (AES, HSLS on 6/3/2026)] |
06/03/2026
| Not Implemented |
| 6400.214(b) | At 10:20AM, Individual #1's physical examinations, dental examinations, dental hygiene plans, assessments, and individual plan were not kept in the home. Staff interviews revealed that Individual #1's records are at the office. [Repeated Violation - 2/25/25, et al and 5/1/25] | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| [The agency does not currently support individuals in community homes. (AES, HSLS on 6/3/2026)] |
06/03/2026
| Not Implemented |
| 6400.32(d) | On 7/22/2025 at 10:11AM, an 8 inch 12 inch paper sign with varying size font, text, color and lettering, hanging on the wall, next to the television in the living room of the home, that read, "Person with INTELLECTUAL DISABILITY AREA; IN AN EMERGENCY SITUATION Please be AWARE they may: NOT RESPOND, RESIST AND RUN AWAY, BE UNAWARE OF DANGER." | An individual shall be treated with dignity and respect. | [The agency does not currently support individuals in community homes. (AES, HSLS on 6/3/2026)] |
06/03/2026
| Not Implemented |
| 6400.163(d) | At 10:53AM, Individual #1 was sleeping in his bed. Individual #1's prescribed medication, Albuterol Sulfate Inhaler was unlocked and accessible on the bed in Individual #1's bedroom. [Repeated Violation 2/25/25 et al and 5/1/25] | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | [The agency does not currently support individuals in community homes. (AES, HSLS on 6/3/2026)] |
06/03/2026
| Not Implemented |
| 6400.166(a)(11) | Individual #1's July 2025 paper medication administration record did not include the diagnosis or purpose for Meloxicam 15mg tab, Clotrimazole 1% cream, and Triamcinolone Acetonide 0.1% cream. | 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. | [The agency does not currently support individuals in community homes. (AES, HSLS on 6/3/2026)] |
06/03/2026
| Not Implemented |
| 6400.166(a)(13) | Individual #1's July 2025 Medication Administration Record did not include Direct Service Worker #2's name who administered Individual #1's prescribed 8:00AM medications on 7/14/2025. . | 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. | [The agency does not currently support individuals in community homes. (AES, HSLS on 6/3/2026)] |
06/03/2026
| Not Implemented |
| 6400.167(a)(1) | Individual #1 is prescribed Amlodipine with instructions to take 1 tablet by mouth daily for hypertension and Lidocaine 5% pad with instructions to place 1 patch onto the skin every 24 hours on thoracic spine were not administered on 7/20/25 at 8AM. Individual #1 is prescribed Clotrimazole 1% cream with instructions to apply topically 2 times a day; this medication was to begin on 7/14/25 and was not administered at 8:00AM from 7/15/25 through 7/20/25 and the 8:00PM medication was not administered as of 7/22/25 at 11:48AM. Individual #1 is prescribed Meloxicam 15mg tab with instructions to take one tablet by mouth daily; this medication was not administered at 8:00PM from 7/14/25 through 7/21/25. Individual #1 is prescribed Triamcinolone Acetonide 0.1% cream with instructions to apply topically to affected areas 2 times a day; this medication was to begin on 7/14/25 and was not administered at 8:00AM from 7/14/25 through 7/20/25 and the 8:00PM medication was not administered as of 7/22/25 at 11:48AM. Individual #1 was prescribed Dulera aerosol inhaler 100-5mcg with instructions to take 2 puffs by mouth twice a day; this medication was not administered at 8:00AM from 7/1/25 through 7/8/25 and 7/10/25 through 7/13/25 before being discontinued on 7/14/25 and was not administered at 8:00PM from 7/1/25 through 7/7/25 and 7/9/25 through 7/13/25 before being discontinued on 7/14/25. [Repeated Violation 2/25/25 et al and 5/1/25] | Medication errors include the following: Failure to administer a medication. | ML MAR has been updated for the following medications: |
06/03/2026
| Not Implemented |
| 6400.186 | At 10:00AM, Individual #1 was unsupervised in the home. Direct Service Worker #1 was across the street at another licensed home. In the supervision care needs of Individual #1's individual plan, last updated on 6/11/25 reads, "[Individual #1] lives in a 1-person site and requires 24/7 supervision due to behaviors that pose as a safety concern. [Individual #1] receives residential habilitation via On-Site Companionship Services. [Individual #1] is unable to have any alone time at home or in the community due to health and safety concerns. [Repeated Violation - 2/25/25, et al and 5/1/25] | The home shall implement the individual plan, including revisions. | [The agency does not currently support individuals in community homes. (AES, HSLS on 6/3/2026)] |
06/03/2026
| Not Implemented |