| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | The hot water in the home exceeded the regulatory 120 degrees. The hot water in the bathroom of the home measured 136.4 degrees. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | maintenance was called and came over to the site to lower the boilers in the basement. so that the water in the apartment was under 120 degrees. |
04/10/2026
| Implemented |
| 6400.77(c) | The first aid kit in the home did not contain a first aid manual. | A first aid manual shall be kept with the first aid kit. | a copy of a first aid booklet was made and put in each first aid kit that was missing on 4/10/2026. |
04/10/2026
| Implemented |
| 6400.142(a) | Individual #1 did not have a dental exam completed annually. Individual #1 has not completed a dental exam including cleaning since 7/2/24. | 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. | the appointment was made for august 26, 2026 this was the earliest that we could get for her. she is also on the fast track for cancelations which we will monitor and try to get for her. |
04/10/2026
| Implemented |
| 6400.144 | Health services including follow-up medical care are not planned for or arranged. Individual #1 had an appointment with a nutritionist on 9/9/25 and was to return in 2-3 months. The follow up appointment in 2-3 months was not scheduled for Individual #1. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| her appointment 4/21/2026 is scheduled and the director will make sure that she gets to this appointment,. |
04/10/2026
| Implemented |
| 6400.151(a) | Staff #1 did not complete a physical exam including TB testing within 12 months prior to working with individuals. Staff #1 was hired on 10/2/25 and began working with individuals on 10/8/25. Staff #1 did not complete a physical exam including TB testing until 10/13/25. Staff #2 did not complete a physical exam biannually. Staff #1 completed a physical exam on 4/17/23 and did not complete another until 6/20/25. | 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. | the director with HR will make sure that all staffs annuals are on a spreadsheet so that they can verify compliance at all times with staff annuals. |
04/10/2026
| Implemented |