| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The provider agency completed a self-assessment of the home on 5/4/25. The regulations, .189a through .217, were not addressed on the self-assessment. These items were left blank. [Repeat Violation- 7/9/24 et al] | 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.
| 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. The CEO has retrained the Residential coordinator on the importance of completing the self assessments in it's entirety, |
06/28/2025
| Implemented |
| 6400.63(a) | On 6/11/25 at 10:46 AM, the hot water temperature measured 135.5 degrees Fahrenheit 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. | 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. Hot water heater was turned down to required temp of 118 |
06/28/2025
| Implemented |
| 6400.64(a) | On 6/11/25 at 10:47 AM, there was food splatter throughout the plate and walls of the microwave in the kitchen of the home. [Repeat Violation- 7/9/24 et al] | Clean and sanitary conditions shall be maintained in the home. | Clean and sanitary conditions shall be maintained in the home. Microwave was cleaned Picture sent via email to licensing inspector. |
06/28/2025
| Implemented |
| 6400.66 | On 6/11/25 at 10:30 AM, the light source outside the front exit of the home was inoperable. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Light bulb was replaced and is not working. Picture was sent via email to licensing inspector |
06/28/2025
| Implemented |
| 6400.68(b) | On 6/11/25 at 10:39 AM, the hot water temperature measured 130.8 degrees Fahrenheit at the bathtub in the bathroom on the first floor of the home. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Hot water heater was turned down to required temp of 118 |
06/28/2025
| Implemented |
| 6400.72(a) | On 6/11/25 at 10:32 AM, there was an accordion screen in the open window in the attic of the home. The screen did not securely fit the window and left a two-inch gap between the screen and the top of the window. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Screen was removed and will be having a screen window company make a screen to fit window. |
06/28/2025
| Implemented |
| 6400.77(b) | On 6/11/25 at 11:30 AM, there was no thermometer 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. | CEO purchased new thermometers for all sites. |
06/28/2025
| Implemented |
| 6400.81(k)(3) | On 6/11/25 at 10:39 AM, there were two soiled and stained pillows without linens on the bed in Individual #1's bedroom. | In bedrooms, each individual shall have the following: Bedding, including pillow, linens and blankets appropriate for the season. | The pillows were removed from home and the ceo purchased new pillows. Receipt sent via email to licensing inspector |
06/28/2025
| Implemented |
| 6400.83(c) | On 6/11/25 at 10:46 AM, there was a soiled cup, silverware, and pot in the sink in the kitchen of the home. | Utensils used for eating, drinking and preparation of food or drink shall be washed and rinsed after each use. | Staff washed dishes immediately returning to site. |
06/28/2025
| Implemented |
| 6400.112(c) | The written fire drill record for the drill conducted on 1/23/25, stated that the drill was completed at "12:00," and did not specify if the fire drill was completed in the AM or PM. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | The CEO has retrained the residential coordinator on the importance of completed fire drill form in it's entirety. |
06/28/2025
| Implemented |
| 6400.112(d) | The fire drill conducted at the home on 4/1/25 had an evacuation time of two minutes, forty-five seconds. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | A fire drill conducted in April 2025 exceeded safe evacuation time (over 2 1/2 minutes), indicating an extended evacuation time. All Staff involved will be trained on the importance of following the designated route and evacuation timing.
2. Systemic Preventive Measures:
The Fire Drill Documentation Form was updated to include:
Time started and ended
Route used
Number of individuals evacuated
Comments on barriers/delays
Staff will be re-trained by 6/30/2025 regarding fire drill procedures, use of alternate routes, and evacuation speed expectations. |
06/28/2025
| Implemented |
| 6400.113(a) | Individual #1 was most recently trained in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the home on 1/3/24. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | An audit was conducted of all individuals annual general fire safety training including evacuation procedures, responsibilities during fire drills and the designated meeting place, ensuring the trainings were completed. |
07/01/2025
| Implemented |
| 6400.142(a) | Individual #1 had a dental examination completed on 5/15/23, and then again on 6/20/24. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Individual did have dental exams completed semi-annually however the appointment summary was missing from his binder. The program specialist reached out to the dental provider Accessible Dental requesting an appointment summary be completed. The office will complete the form 7/10 at the next scheduled exam. |
07/10/2025
| Implemented |
| 6400.212(b) | The date of Individual #1's most recent physical examination was written over on the front and the back of the documentation form, rendering the original date illegible. | Entries in an individual's record shall be legible, dated and signed by the person making the entry.
| All records were reviewed and where possible clarification were obtained. Program staff were immediately reminded of the documentation requirement during a team meeting following licensing and receiving pre liminary findings. |
06/12/2025
| Implemented |
| 6400.214(b) | On 6/11/25 at 11:35 AM, the most recent copies of Individual #1's dental hygiene plan, dental examination, and psychiatric evaluation were not present at the home. [Repeat Violation- 7/9/24 et al] | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| Atlantis Program specialist reviewed resident files in the home and have updated the required documents. Weekly checks will be conducted by the house supervisor to ensure all medical summaries are present in the resident files. Monthly audits will be conducted by the program specialist to ensure the resident binder contains all required documents. |
06/20/2025
| Implemented |
| 6400.216(a) | On 6/11/25 at 10:46 AM, Individual #1's Service Plan, dated 5/16/22, and opened letters addressed to Individual #1 from the Department of Human Services and the Office of Income Maintenance containing Individual #1's personal, identifiable information, were unlocked and accessible on the kitchen table. | An individual's records shall be kept locked when unattended.
| Mail was immediately removed from table and placed in locked office. |
06/28/2025
| Implemented |
| 6400.32(r)(1) | On 6/11/25 at 10:36 AM, there was a turn locking mechanism on the inside with a thumbnail locking mechanism on the outside of the door leading to Individual #1's bedroom. Individual #1 has not been provided with a designated mechanism to lock and unlock the door independently. | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | An individual has the right to lock the individual's bedroom door. All individuals locks were updated with key and given to individual. Picture was sent via email to licensing inspector. |
06/28/2025
| Implemented |
| 6400.32(r)(5) | On 6/11/25 at 10:36 AM, there was a turn locking mechanism on the inside with a thumbnail locking mechanism on the outside of the door leading to Individual #1's bedroom. Staff did not have a designated mechanism to lock and unlock the bedroom door in case of an emergency. | Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door. | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. The locks were replaced with new locks with keys and provided a copy to individual. |
06/28/2025
| Implemented |
| 6400.163(d) | On 6/11/25 at 10:50 AM, there were two single dose packets of Tylenol Extra Strength, unlocked and accessible in the first aid kit on the shelf in the cabinet above the counter in the kitchen 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. | The single packs of Tylenol were immediately removed from the first aid kit and placed in the designated locked storage area. All other first aid kits in other sites were inspected to ensure no medications were being stored improperly. |
06/11/2025
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medications to treat symptoms of a psychiatric illness. The psychiatric medication reviews completed on 1/28/25 and 4/22/25 did not include the medications reviewed and the reason for prescribing them. [Repeat Violation- 7/9/24 et al] | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | All Psychiatric reviews will be scheduled to be completed by psychiatric provider. The Psychiatric medication review appointment summary form has been updated to reflect the reasons for prescribing the medication as well as the need to continue the medication and necessary dosage. Files are being audited to ensure compliance and corrections made where necessary. |
07/01/2025
| Implemented |
| 6400.166(b) | Individual #1's prescribed medication, Vitamin D3, was not initialed as having been administered on 6/4/25, 6/5/25, 6/6/25, 6/9/25, and 6/10/25. [Repeat Violation- 7/9/24 et al] | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The responsible staff member was immediately retrained on the correct procedure for documenting medication administration. On 6/13/2025 this staff member was retrained on proper Mar documentation procedures including immediate documentation after administration. The use of acceptable documenting codes and steps to follow when a dose is missed, refused or delayed. Staff reviewed the Medication Administration Policy and signed acknowledgment forms. |
06/13/2025
| Implemented |
| 6400.195(a) | The provider agency is locking the knives and other sharp objects in the home due to Individual #1's behavioral issues. Individual #1 does not have a restrictive procedure plan that has been reviewed and approved by a human rights team. | For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures. | The use of the restrictive procedure was immediately suspended until proper authorization and planning are completed. A team meeting including the individual, behavior specialist service coordinator will be held the week of 7/7/2025 to review and update the Behavior Support plan and ISP. |
06/13/2025
| Implemented |