| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(f) | On 1/21/2026 at 11:57AM, there was a trash receptable with no lid with plastic bags and miscellaneous articles of trash protruding from the top in the back yard of the home. Additionally, there was another trash receptacle next to it with a lid with plastic bags containing miscellaneous articles of trash preventing the lid from closing. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | Trash can lids have been immediately closed. New trash cans will be purchased. Staff will be retrained to emphasize the importance of having garbage cans closed due to penetration of insects and rodents. Damaged trash cans will be reported to the site supervisor for immediate replacement. Copy of the training will be included for POC |
02/22/2026
| Implemented |
| 6400.65 | On 1/21/2026 at 12:06PM, the cover for the mechanical ventilation fan was hanging from the ceiling in the bathroom on the second floor of the home. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Mechanical vent fan was repaired immediately after 1/21/2026 on the second floor of the bathroom. Staff will be retrained to report any broken vents and clean any dirty vents when needed. proof of trianing will be submitted as part of the POC |
02/22/2026
| Implemented |
| 6400.66 | On 1/21/2026 at 12:15PM, there was no source of light at the side exit of the home. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| There will be an light applied to the side exit of the home (1/24/2026). The proof of the repair will be submitted as part of the POC. Staff will monitor for any malfunction of lights and report any need for light replacement . Training will be given to emphasize reporting any lights that are malfunctioning. Training will be submitted for POC. |
02/22/2026
| Implemented |
| 6400.67(a) | On 1/21/2026 at 12:04PM, the left door was broken off from the armoire in Individual #1's bedroom. | Floors, walls, ceilings and other surfaces shall be in good repair. | Amoire door has been repaired and replaced. 1/24/2026. Staff will be retrained to report any broken or ripped furniture for repair or replacement . Staff will report any disrepair to the site supervisor. Training will be supplied as part of the POC |
02/22/2026
| Implemented |
| 6400.67(b) | On 1/21/2026 at 11:52AM, there was no transition strip on the last two inches of landing at the top of the interior stairs leading to the basement of the home making the floor uneven posing a tripping hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Transition strip has been immediately repaired. (1/24/2026). Picture of the repair will be submitted for POC. Staff will be trained to notify the site supervisor of any hazard in need of immediate repair. Copy of the training will be submitted for the POC |
02/22/2026
| Implemented |
| 6400.72(b) | On 1/21/2026 at 12:08PM, there was a one-inch by one-half-inch hole and a one-inch rip in the screen in the window in the vacant bedroom on the second floor of the home. | Screens, windows and doors shall be in good repair. | Screen in the window to be replaced immediately, 1/21/2026. Staff will be instructed to replace any screens as needed and report any ripped or screens needing replaced to the site supervisor or house manager. |
02/22/2026
| Implemented |
| 6400.73(a) | On 1/21/2025 at 11:52AM, there was no railing on the four, interior stairs leading to the basement of the home. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | A railing will be immediately placed on the four interior stairs leading to the basement (1/24/2026). A picture of the repair will be provided as part of the POC. |
02/22/2026
| Implemented |
| 6400.75(a) | On 1/21/2026 at 11:52AM, the door on the first floor of the home leading to the basement opened inward directly toward four stairs with no landing. | A landing shall be provided beyond each interior and exterior door that opens directly into a stairway. | The door on the first floor has been immediately removed and will not be replaced with another. (1/24/2026) A picture of the door not being attached to the top of the steps will be submitted as part of the POC. |
02/22/2026
| Implemented |
| 6400.77(b) | On 1/21/2026 at 12:50PM, there were no tweezers in the home's first aid kit. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | Purchased first aid kit did not have tweezers inside of the kit. Tweezers immediately purchased and placed in the kit (1/21/2026). All kits will assure having tweezers in the kit when purchased. Site supervisor/house manager will monitor kits for needed supplies and expired content. |
02/22/2026
| Implemented |
| 6400.101 | On 1/21/2026 at 11:57AM, the exit door on the side exit of the home was locked and required a skeleton key to unlock from the inside posing an obstructed egress. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The door with the skeleton key to the outside of the side door has been replaced with a new door with easy to open door knob and lock (1/24/2026). There will be no use of doors with skeleton keys moving forward. |
02/22/2026
| Implemented |
| 6400.110(e) | On 1/21/2026 at 12:13PM, the smoke alarm on the first floor was not interconnected with the smoke alarms on the second floor and the basement of the home. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | First floor fire alarm has been replaced 1/21/2026. Fire alarms will be inspected for interconnection and replaced if needed . Monthly fire drill will continue as required. Staff will be retrained to report any malfunctioning fire alarms, including interconnection issues or beeping alarms that may need new batteries (if applicable) to the house manager immediately for replacement. |
02/20/2026
| Implemented |
| 6400.151(a) | Direct Service Worker #1's biennial physical examinations were completed on 12/8/2021 and again on 7/11/2024. Direct Service Worker #2, date of hire 12/15/2025, completed their pre-employment physical examination on 12/21/2025. [Repeat Violation, 1/30/2025] | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Direct worker #1 physical exam has been completed as of biannual physicals on a tracker. Program specialist will monitor for dates of biannual physicals. Staff will be given a 60 day notification before that the physical needs to be completed. Program specialist will continue to use the tracker for notifications. |
02/22/2026
| Implemented |
| 6400.151(c)(2) | Direct Service Worker #2, date of hire 12/15/2025, completed their pre-employment, Tuberculin skin test via Mantoux method on 12/21/2025. [Repeat Violation, 1/30/2025] | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | No new hires will be able to work until the completed physical and tb test are completed in its entirety. New hire checklist will include notation that employee will not work until the physical has been completed and the tb test has been completed as will. |
02/22/2026
| Implemented |
| 6400.181(e)(2) | Individual #1's assessment, completed 5/25/2025, did not include likes and dislikes of the individual. | The assessment must include the following information: The likes, dislikes and interest of the individual. | Assessment paperwork will be immediately corrected and completed to include the likes, dislikes, and the interests of the individual.
Completed assessment will be submitted for the POC. Revised and corrected assessment will be submitted for the POC. Original
assessment paperwork was revised. The needed sections were omitted accidentally. |
02/22/2026
| Implemented |
| 6400.216(a) | On 1/21/2026 at 12:54PM, a binder containing the personal, identifiable information, service plans, assessments and other documents belonging to an individual that previously resided in the home was unlocked and unattended in a cabinet in the dining room of the home. | An individual's records shall be kept locked when unattended.
| All personal information and or records will be locked when unattended. Staff will be retrained emphasizing the importance of keeping records locked when unattended. Staff must lock unattended records even if they are in the home by themselves. Record of the training will be sent for the POC. |
02/22/2026
| Implemented |
| 6400.46(b) | Direct Service Worker #1, date of hire 6/20/2022, was most recently trained in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place, smoking safety procedures, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered on 1/5/2025. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | DSW #1 has completed annual fire safety training as of 1/23/2026. Annual trainings will occur starting this year 1/1/2026-12/31/2026 for all employees to ensure timely completion to include annual safety training. Documentation of training will be submitted as part of the POC. |
02/22/2026
| Implemented |
| 6400.52(c)(5) | Direct Service Worker #1 did not participate in training to include safe and appropriate use of behavior supports for the individuals they work directly with during the 6/20/2024-6/19/2025 annual training year. | 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. | DSW #1 has been immediately trained on the ISP for each individual they are working directly with and the safe and appropriate use of behavior supports for each individual they work with. A copy of the ISP training will be provided as part of the POC. Staff will switch to annual trainings for the 2026 year to ensure that all annual trainings are being completed in a timely manner. Staff will have to take at least two trainings a month equaling 2 hours or more to ensure that the 24 hours of annual trainings are being met |
02/22/2026
| Implemented |
| 6400.52(c)(6) | Direct Service Worker #1 did not participate in training to include the implementation of the individual plan for the individuals they work directly with during the 6/20/2024-6/19/2025 annual training year. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | DSP#1 has been immediately trained on the ISP for each individual they are working directly with and the safe and appropriate use of behavior supports for each individual they work with. A copy of the ISP training will be provided as part of the POC. Staff will switch to annual trainings for the 2026 year to ensure that all annual trainings are being completed in a timely manner. Staff will have to take at least two trainings a month equaling 2 hours or more to ensure that the 24 hours of annual trainings are being met |
02/22/2026
| Implemented |
| 6400.163(b) | On 1/21/2026 at 12PM, at least five doses of Individual #1's prescribed medications, Vitamin D3, Depakote ER, Haloperidol, Lexapro, Prazosin HCL and Trazodone were previously removed from their originally labeled containers and placed in a plastic, weekly medication organizer. | A prescription medication may not be removed from its original labeled container in advance of the scheduled administration, except for the purpose of packaging the medication for the individual to take with the individual to a community activity for administration the same day the medication is removed from its original container. | Medications that were prepackaged were immediately disposed of 1/21/2026. Staff have been retrained emphasizing that medications must remain in their original labeled containers and medications locked until the moment of administration unless being packed for a same-day community outing. Copy of the training will be submitted for the POC |
02/22/2026
| Implemented |
| 6400.163(d) | On 1/21/2026 at 12PM, Individual #1's prescribed medications and a bottle of Equate Liquid Cold and Flu medication was unlocked and accessible in a cabinet in the dining room of the home. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | Staff will be retrained emphasizing the importance of keeping medicine containers locked at all times when unattended. Documentation of the training will be submitted for POC. |
02/22/2026
| Implemented |
| 6400.166(a)(11) | Individual #1's January 2026 Medication Administration Record did not include a diagnosis or purpose for Vitamin D3 and Depakote. [Repeat Violation, 1/30/2025] | 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. | Individual 1 MAR has been immediately corrected to include the diagnosis. Company nurse will review all MARs before the month of Medication administration to ensure that all MARS are complete and accurate to include the diagnose or purpose for the medication. Staff will be retrained to emphasize that the diagnosis for each medication should be on the MAR before administering the
medication. Record of training will be included for the POC. |
02/22/2026
| Implemented |
| 6400.166(a)(13) | Individual #1's January 2026 Medication Administration Record did not include the full name of the Direct Service Workers that administered the medications. | 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. | Individual #1 MAR has been corrected to include the full name of the dsw that administered the medication. Staff will be retrained emphasizing the importance of signing the medication administration record before medication can be administered. Record of training will be submitted as for the POC |
02/22/2026
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not include identifying marks. [Repeat Violation, 1/30/2025] | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Individual #1 record has been completed to include identifying marks. Individual records will be completed in there entirety annually and as needed. There will be no blanks on the individual records. Program specialist will ensure that the individual record is completed in its entirety. |
02/22/2026
| Implemented |