| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.85(a) | An in-ground swimming pool shall be fenced with a gate that is locked when the pool is not in use. The home has an in-ground swimming pool and at the time of the inspection, the pool had a winter cover on it, but anyone could easily access the pool from the kitchen exit or bilco door exit. The only fencing/gate was the one around the property/yard. | An in-ground swimming pool shall be fenced with a gate that is locked when the pool is not in use. | Install a fence with a gate that can be locked when not in use, which will ensure safety. On 12/22/2025, BroMack received an estimate on a 4 foot high fence with a locking gate to go around the pool. Deposit was made on 1/5/2026. Train all staff on using and locking the gate and on the requirement of keeping the gate locked at all times when not in use. |
02/28/2026
| Implemented |
| 6400.141(c)(10) | Individual #1's physical examination dated 1/3/25 did not include if they were free from communicable disease as this section of the form was left blank. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | The Physical Form dated 1/3/2025, which was reviewed by the Licensor was a Pre-Admission Physical and was one that the Individual's PCP used.
Once residing with BroMack, on 9/19/25, the Individual had a Physical completed using our form. This Physical does include the Physician's statement that this Individual is free from communicable disease. The BroMack Physical Form does include a section for the Physician's statement regarding communicable diseases. |
09/19/2025
| Implemented |
| 6400.151(c)(3) | Staff #1's physical dated 7/14/25 and it did not include a signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | Staff immediately went to the Doctor on 12/18/2025 to get a TB shot to indicate that she is free from Communicable Diseases. |
12/20/2025
| Implemented |
| 6400.32(r) | Individual #1 did not have a lock on their bedroom door. On 5/8/25 Individual #1 signed an agency form indicating that that did not wish to have a lock on their door, however there was no documentation on their Individual Support Plan nor on the agency form that the Individual was explained all of their rights in a manner to allow the individual to have proper informed consent when making a decision to utilize their rights. | An individual has the right to lock the individual's bedroom door. | On 12/22/25, the Individual's ISP was updated to reflect the conversation had on 10/27/25 during her ISP meeting where she stated she did not want a lock on her bedroom door. |
12/22/2025
| Implemented |
| 6400.195(a) | During the inspection, located in Individual #1's file was a Technology use agreement dated 5/29/25 between Individual #1 and the agency. I, Individual #1, choose to have this agreement in place to help me manage my phone and tablet use so that I can be safe. I will keep my phone calls with my boyfriend to 5 minutes and use the phone in common spaces of the home (living room, kitchen, or basement if staff is there). I'll use my tablet when staff are with me so they partner with me to make sure that I am being safe. I would like for staff to sit side by side with me when partnering during tablet time. I want to stay focused during social times. If I need help, I'm okay with staff reminding me and I am in agreement with staff storing my tablet so that they can make sure it is safe. I want regular check-ins to male sure this agreement works for me. There is no Restrictive Procedure Plan in place for Individual #1. | 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. | On 12/18/25, the Partnering Agreement was destroyed/shredded. Supervisors and Administration were trained to understand this individual does not have any restrictions and there are no restrictive procedures in place. |
12/18/2025
| Implemented |