| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.104 | The notification to the fire department does not include the full address. It does not include the city, State or Zip code. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Notification was updated and sent on 3/20/26 (Supporting Document S15). |
03/20/2026
| Implemented |
| 6400.110(e) | The fire alarms, while functioning independently after troubleshooting, were not interconnected during the inspection. | 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. | Fire alarms were interconnected by the evening of 3/19/26. |
03/19/2026
| Implemented |
| 6400.141(c)(2) | Individual #1's annual physical was completed on November 3, 2025, but the evaluation of systems section was only completed with "no" checked and comments for normal findings for extremities and nervous system. Everything else was left blank. | The physical examination shall include: A general physical examination. | The blanks on the physical were completed by the doctor on 4/7/26 (Supporting Document S27). |
04/07/2026
| Implemented |
| 6400.141(c)(4) | Individual' #1s annual physical was completed on November 3, 2025. The vision and hearing screening sections were left blank. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | The blanks on the physical were completed by the doctor on 4/7/26 (Supporting Document S27). |
04/07/2026
| Implemented |
| 6400.141(c)(8) | Individual'#1's annual physical was completed on November 3, 2025. The mammogram section had "ordered" entered, but this was also on the intake physical dated October 28, 2024. However, after requesting documentation of a mammography appointment, the agency provided an email dated 3/19/26 from the individual's father that stated he coordinated her care based on their mutual schedules and identified April 31, 2026 at Methodist but as a walk-in with him. This would be nearly 5-months after the annual physical exam. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | The mammogram was completed on 3/31/26 (Supporting Document S16). |
03/31/2026
| Implemented |
| 6400.141(c)(14) | Individual'#1's annual physical was completed on November 3, 2025. There were no comments for information pertinent to diagnosis and treatment in case of emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The blanks on the physical were completed by the doctor on 4/7/26 (Supporting Document S27). |
04/07/2026
| Implemented |