| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 20.34 | The agency had an announced Renewal Inspection with the Department that was scheduled and occurred between 7/23/2026 to 7/24/2026. At 9:02 AM on 7/23/2026, the Department emailed the agency the inspection sample of homes, individuals and staff prior to the Department's arrival at approximately 10:00 AM. The Department conducted an Entrance Conference with the agency from 10:10 AM to 10:28 AM on 7/23/2026. The agency did not provide access to all sample records despite the Department's multiple requests, which occurred between 10:20 AM and 12:20 PM on 7/23/2026. At approximately 12:28 PM on 7/23/2026, the Department asked Chief Financial Officer #1 for an estimated time of arrival for the outstanding records as well as the reason for the delay in access. Chief Financial Officer #1 contacted Operations Manager #2 and ascertained that a portable flash drive, containing the outstanding records, had been misplaced at the home of Operations Manager #2, and that the agency's central electronic database did not contain such records. At approximately 1:15 PM on 7/23/2026, the agency was able to provide only partial access to the outstanding inspection records. | The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agentsof the Department to privately interview staff and clients. | During the announced Renewal Inspection on 07/23/2026, the agency delayed providing the Department with access to all requested sample records. Some of the requested documentation had been maintained on a portable flash drive that was not immediately available at the time of the inspection, and the agency's centralized electronic record system did not contain all of it.
The agency acknowledges that records required for inspection must be readily accessible to authorized representatives of the Department during both announced and unannounced inspections. The agency has reviewed its records storage process and is transitioning required inspection and compliance documentation to a centralized electronic records system accessible to authorized management personnel. The agency will no longer rely on a portable flash drive as the primary storage location for records required for regulatory review.
The Operations Manager and Assistant Director will use the 30-day corrective action period to review required agency, individual, and staff records and verify that applicable documentation is maintained in the centralized system and can be accessed promptly when requested by the Department. |
09/13/2026
| Implemented |
| 6400.64(a) | At 11:26 AM on 7/24/2026, the home's kitchen had the following sanitation issues: in the top left cabinet, there was an accumulation of spilled spices and salt; food particles and splatter were sprawled over the wall's entirety near the stove; and mustard was splattered on the wall above the pantry cupboard. | Clean and sanitary conditions shall be maintained in the home. | The sanitation deficiencies identified during the inspection were corrected on 07/24/2026. The accumulation of spilled spices and salt in the kitchen cabinet, and the food splatter and residue on the walls near the stove and pantry cupboard, were cleaned and sanitized.
Although the identified conditions were corrected immediately, the agency will use the 30-day corrective action period to strengthen its environmental monitoring process and ensure that kitchens and other areas of the home are maintained in clean and sanitary condition on an ongoing basis. |
09/13/2026
| Implemented |
| 6400.72(a) | At 11:36 AM on 7/24/2026, located in the home's basement, there were two block glass windows with operable, opening middle vents that were not screened. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | During the inspection on 07/24/2026, two glass-block windows in the basement were found to have operable middle vents without screens secured in the window openings. The screens for these windows had become dislodged and were subsequently located outside near the windows when maintenance responded to inspect the area.
The identified deficiency was corrected on 07/24/2026. Maintenance securely reinstalled the screens in the applicable window openings and verified they were properly secured.
Although the physical deficiency was corrected immediately, the agency will use the 30-day corrective action period to review operable windows and applicable doors throughout its residential locations and implement an enhanced monitoring process to identify missing, loose, damaged, or dislodged screens before they result in future noncompliance. |
09/13/2026
| Implemented |
| 6400.83(a) | Individual #1's Service Plan, last updated 7/15/2026, stated, "[Individual #1] is overall safe around knives" and "In the summer, [Individual #1] grills a lot. [Individual #1] has been eating a lot of fish and chicken." However, at 1:35 PM on 7/23/2026, the agency explained that they did not purchase any steak or cooking knives for the home. At 11:26 AM on 7/24/2026, the home did not contain such cooking equipment. | A home shall have a kitchen area with a refrigerator, sink, cooking equipment and cabinets for storage. | The agency reviewed Individual #1's current assessment and Service Plan regarding the safe use of knives and household utensils. The assessment indicated that Individual #1 uses utensils appropriately and uses knives safely and correctly, while the Service Plan contained language indicating that Individual #1 did not have access to knives. Individual #1 did not have an approved restrictive procedure limiting access to household sharp utensils.
The discrepancy was corrected, and appropriate kitchen utensils, including knives necessary for normal cooking and meal preparation, were made available in the home consistent with Individual #1's assessed abilities, rights, and current plan. The agency also reviewed the home to ensure the kitchen contained the equipment and household items necessary for normal use.
The Operations Manager and Assistant Director will use the 30-day corrective action period to verify continued implementation and ensure that restrictions are imposed only when supported by the individual's assessed needs, current plan, and applicable approval requirements. |
09/13/2026
| Implemented |
| 6400.83(c) | At 11:27 AM on 7/24/2026, located in the home's kitchen and stored within the cupboard above the sink, was an unwashed Tupperware container that contained food particles, appearing to be dried spaghetti sauce. | Utensils used for eating, drinking and preparation of food or drink shall be washed and rinsed after each use. | During the inspection on 07/24/2026, an unwashed food storage container with dried food particles was found in the kitchen cupboard. Once the condition was discovered, the item was immediately removed from the cupboard and properly washed and rinsed. The kitchen cabinets and food storage areas were also reviewed to ensure that utensils and containers were clean before storage.
Although the identified deficiency was corrected immediately on 07/24/2026, the agency will use the 30-day corrective action period to reinforce sanitation expectations with Direct Support Professionals (DSPs) and implement enhanced monitoring of kitchen and food-preparation areas. |
09/13/2026
| Implemented |
| 6400.141(c)(13) | Individual #1's current physical examination, completed on 9/17/2025, indicated, "N/A," in the field regarding allergies. However, Individual #1 has medicinal and environmental allergies in accordance with their Service Plan, last updated 7/15/2026, which documented the following allergies: Risperdal, Thorazine, and Seasonal Allergies. | The physical examination shall include: Allergies or contraindicated medications. | Individual #1's physical examination dated 09/17/2025 documented "N/A" in the allergies section; however, Individual #1's current Service Plan identifies allergies to Risperdal, Thorazine, and seasonal allergies.
The agency reviewed Individual #1's medical and health records to verify the documented allergies. It corrected the identified discrepancy so that the individual's health documentation accurately reflects known allergies and contraindicated medications.
The agency will use the 30-day corrective action period to review applicable individual health records and physical examination documentation to identify and correct any additional discrepancies related to allergies or contraindicated medications. |
09/13/2026
| Implemented |
| 6400.171 | At 11:28 AM on 7/24/2026, the refrigerator located in the home's kitchen contained the following foods that were unprotected from contamination: a one-gallon jug of Great Value Whole Milk with a sell-by-date of 6/11/2026; an 18- pack carton of Great Value Eggs with a best-buy-date of 6/13/2026; a green pepper in the crisper drawer that was decomposed and deteriorated with visible black spots that appeared to be mold; and an open, unsealed package of cream cheese. | Food shall be protected from contamination while being stored, prepared, transported and served.
| During the inspection on 07/24/2026, food items were identified in the refrigerator that were expired, deteriorated, or not properly sealed, including milk, eggs, a deteriorated green pepper, and an open package of cream cheese. Upon discovery, the identified food items were immediately removed and discarded. The refrigerator and remaining food items were reviewed to ensure that food was properly stored and protected from contamination.
As part of the corrective action, Direct Support Professionals (DSPs) will be retrained on the agency's Food Storage and Disposal Policy, including proper food storage, protection from contamination, monitoring of expiration and use-by dates, disposal of expired or spoiled food, and proper sealing and storage of opened food items.
The agency will use the 30-day corrective action period to complete the staff retraining and fully implement and verify the enhanced food-storage monitoring process. |
09/13/2026
| Implemented |
| 6400.181(a) | Individual #1's current assessment was completed on 8/4/2025. However, annual compliance could not be determined, as the agency did not provide the previous assessment. [Repeated Violation-8/13/25, et al.] | 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. | Individual #1 had an assessment dated 08/04/2025; however, during the inspection, the agency was unable to provide the previous assessment necessary for the Department to verify compliance with the annual assessment requirement.
The identified deficiency has been addressed. Individual #1's assessment was reviewed and updated on 07/31/2026, and the agency ensured that the current assessment and applicable supporting documentation are maintained and readily accessible within the individual's record.
Because this was identified as a repeated violation, the agency will use the 30-day corrective action period to conduct an expanded review of individual assessment records and fully implement an enhanced tracking and record-retention system to ensure assessments are completed within required timeframes and documentation necessary to verify compliance is readily accessible. |
09/13/2026
| Implemented |
| 6400.181(e)(9) | Individual #1's current assessment was completed on 8/4/2025. However, this assessment did not include documentation of the individual's disability. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | Individual #1's assessment dated 08/04/2025 did not include the required documentation of the individual's disability, including applicable functional and medical limitations.
The identified deficiency was corrected when Individual #1's assessment was reviewed and updated on 07/31/2026. The updated assessment includes documentation of the individual's disability and applicable functional and medical limitations.
The agency will use the 30-day corrective action period to review applicable assessments across its residential programs and verify that required assessment components are present and sufficiently documented. |
09/13/2026
| Implemented |
| 6400.181(e)(10) | Neither Individual #1's current assessment, completed on 8/4/2025, nor their content-of-records included a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | Individual #1's assessment dated 08/04/2025, and the content of the records did not include the required lifetime medical history.
The identified deficiency was corrected when Individual #1's assessment was reviewed and updated on 07/15/2026. The updated assessment includes the required lifetime medical history based upon available medical and health information maintained or obtained by the agency.
The agency will use the 30-day corrective action period to review applicable individual assessments and records to verify that lifetime medical histories are included as required. |
09/13/2026
| Implemented |
| 6400.181(e)(11) | Neither Individual #1's current assessment, completed on 8/4/2025, nor their content-of-records included an applicable psychological evaluation or documentation attempting to obtain one. | The assessment must include the following information: Psychological evaluations, if applicable. | Individual #1's assessment dated 08/04/2025, and the content of the records did not include an applicable psychological evaluation or documentation demonstrating attempts to obtain one.
The identified deficiency was addressed during the review and update of Individual #1's assessment on 07/31/2026. The agency reviewed the individual's records for the applicable psychological evaluation and ensured that the updated record included the applicable evaluation or documentation of the agency's efforts to obtain it.
The agency will use the 30-day corrective action period to review applicable individual records to verify that, when applicable, psychological evaluations or documentation of efforts to obtain them are maintained as required. |
09/13/2026
| Implemented |
| 6400.46(b) | Direct Service Worker #3's content of records did not include annual completion of fire safety training. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Direct Service Worker #3 completed fire safety training through the agency's online training system; however, the employee's record did not contain documentation sufficient to verify completion of all required annual fire safety training components.
The agency reviewed its fire safety training and documentation process and determined that, as part of its corrective action, required fire safety training will be conducted in person to provide greater oversight and verification that all applicable regulatory components are addressed and documented.
The in-person training will include general fire safety, evacuation procedures, responsibilities during fire drills, designated meeting places, smoking safety procedures, when applicable, use of fire extinguishers, smoke detectors, and fire alarms, and notification of the local fire department, when applicable.
The Operations Manager and Assistant Director will use the 30-day corrective action period to complete the applicable in-person retraining, review DSP training records, and implement the enhanced training and documentation process. |
09/13/2026
| Implemented |
| 6400.46(d) | Direct Service Worker #2 completed a two-year certification training in first aid, Heimlich techniques and cardio-pulmonary resuscitation on 2/28/2024, but had not since completed a subsequent training as of 7/24/2026. [Repeated Violation-8/13/25, et al.] | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Direct Service Worker #2 completed certification training in First Aid, Heimlich techniques, and cardiopulmonary resuscitation (CPR) on 02/28/2024; however, a subsequent annual training was not completed as required.
The agency will ensure that Direct Service Worker #2 completes the required First Aid, Heimlich, and CPR training. In addition, the agency will review applicable staff training records to identify any other employees who require initial or annual training and ensure that identified deficiencies are corrected within the corrective action period.
Because this was identified as a recurring violation, the Operations Manager and Assistant Director will implement an enhanced training-tracking system that records each employee's required training, completion date, and next annual due date. The agency will use the 30-day corrective action period to review applicable staff records, complete outstanding training, and verify implementation of the enhanced tracking process. |
09/13/2026
| Implemented |
| 6400.52(c)(3) | Direct Service Worker #3's annual training for the 2025 calendar year did not include completion of the required training topic on individual rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Direct Service Worker #3's annual training record for the 2025 calendar year did not include completion of the required training topic regarding individual rights. Direct Service Worker #3 has since completed the required individual rights training through ODP for the 2026 calendar year.
The agency verified completion of the required 2026 training and will review applicable DSP training records to ensure that required ODP trainings are completed and properly documented.
The Operations Manager and Assistant Director will use the 30-day corrective action period to review applicable staff training records and to fully implement an enhanced training-tracking and verification process. |
09/13/2026
| Implemented |
| 6400.52(c)(6) | Direct Service Worker #3's annual training for the 2025 calendar year did not include completion of the required training topic on implementation of the individual plan relative to individual-specific reviews of service plans. | 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. | Direct Service Worker #3 had access to the current Individual Plan for the individual supported; however, the employee's 2025 annual training record did not include documentation verifying completion of the required annual, individual-specific review and training on the implementation of the Individual Plan.
The agency will provide and document an in-person review of the applicable Individual Plan with Direct Service Worker #3. The agency will also review applicable DSP training records to verify that required individual-specific plan reviews have been properly documented.
The Operations Manager and Assistant Director will use the 30-day corrective action period to complete applicable reviews and implement an enhanced process for documenting individual-specific plan training. |
09/13/2026
| Implemented |
| 6400.165(f) | Individual #1 is currently prescribed medication to treat symptoms of a diagnosed psychiatric illness. However, Individual #1's content-of-records did not include a written protocol or plan to address the social, emotional, and environmental needs of Individual #1 relative to the symptoms of the psychiatric illness. | 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. | Individual #1 is prescribed medication to treat symptoms of a diagnosed psychiatric illness. At the time of inspection, the individual's record did not contain the required written protocol addressing the individual's social, emotional, and environmental needs related to the symptoms of the psychiatric illness.
The identified deficiency has been corrected. The agency developed and completed a Social, Emotional, and Environmental Plan (SEEP) for Individual #1 to address the individual's social, emotional, and environmental needs related to the symptoms for which psychiatric medication is prescribed.
As part of the agency's systemic corrective action, the agency reviewed individuals across its residential programs who receive medication to treat symptoms of a diagnosed psychiatric illness and completed SEEPs for all applicable individuals.
The Operations Manager and Assistant Director will use the 30-day corrective action period to verify that the completed SEEPs are appropriately maintained within the applicable individual planning documentation and that the enhanced SEEP tracking and review process is fully implemented. |
09/13/2026
| Implemented |
| 6400.181(f) | Individual #1s current assessment, completed on 8/4/2025, was sent to plan team members on 8/4/2025, for an individual plan meeting that occurred on 8/27/2025. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The Department's inspection finding states that Individual #1's assessment, completed on 08/04/2025, was provided to the Individual Plan team members on 08/04/2025 for an Individual Plan meeting that occurred on 08/27/2025.
Upon further review of Individual #1's approved ISP and supporting records, the agency verified that the ISP Annual Review Meeting was held on 12/15/2025, not 08/27/2025. The approved ISP identifies the Annual Review Meeting Date as 12/15/2025 and further documents within the plan that the ISP meeting was held on 12/15/2025.
Based upon the documented Annual Review ISP Meeting date of 12/15/2025, the assessment provided on 08/04/2025 was provided to the Individual Plan team more than 30 calendar days before the Annual Review ISP Meeting.
Individual #1's assessment was subsequently reviewed and updated on 07/31/2026. The agency will use the 30-day corrective action period to review assessment distribution records and ISP meeting documentation for applicable individuals to ensure that assessment completion dates, distribution dates, and ISP meeting dates are accurately documented and readily available for regulatory review. |
09/13/2026
| Implemented |