| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.113(a) | Individual #1 began receiving respite services with the agency on 5/12/2025. Individual #1 was not instructed 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 upon the start of their respite services. | 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. | The Program Director, Quality Assurance Associate, Program Managers, and Program Specialists have been retrained on the regulation. The person received the annual fire safety training on 7/10/25 and will receive training annually. Licensing personnel reviewed the document during inspection. |
12/12/2025
| Implemented |
| 6400.141(a) | Individual #1 began receiving respite services with the agency on 5/12/2025. Individual #1 did not have a physical examination completed prior to the start of their respite services. Individual #1's physical examination was completed on 10/24/2025. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The Program Director, Quality Assurance Associate, and Program Specialists have been retrained on the regulation. The individual received a physical examination on 10/24/25 and will receive a physical annually thereafter. Licensing personnel reviewed the document during inspection. |
12/12/2025
| Implemented |
| 6400.141(c)(4) | Individual #1 began receiving respite services with the agency on 5/12/2025. Individual #1 did not have a vision or hearing screening completed prior to the start of their respite services. Individual #1's vision screening was completed on 10/22/2025. Individual #1's hearing screening was completed at their physical examination on 10/24/2025. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | The Program Director, Quality Assurance Associate, and Program Specialists have been retrained on the regulation. The individual received a physical examination on 10/24/25, the document included hearing and vision, and will receive a physical annually thereafter. Licensing personnel reviewed the document during inspection |
12/12/2025
| Implemented |
| 6400.141(c)(7) | Individual #1 began receiving respite services with the agency on 5/12/2025. Individual #1 did not have a gynecological examination completed prior to the start of their respite services. Individual #1's gynecological examination was completed on 11/5/2025. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | The Program Director, Quality Assurance Associate, and Program Specialists have been retrained on the regulation. The individual received a gynecological examination on 11/5/25, the document included hearing and vision and will receive a physical annually thereafter. Licensing personnel reviewed the document during inspection |
12/12/2025
| Implemented |
| 6400.181(a) | Individual #1 began receiving respite services with the agency on 5/12/2025. The individual exceeded the 31 days of temporary respite care and was fully admitted into the agency on 7/13/2025. Individual #1's initial assessment should have been completed no later than 9/11/2025; however, as of 11/25/2025, an assessment had not yet been completed. | 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. | The Program Director, Quality Assurance Associate, and Program Specialists have been retrained on the regulation. The assessment was completed on 12/1/25 and is due 6/1/25 for the annual requirement. |
12/12/2025
| Implemented |
| 6400.34(a) | Individual #1 began receiving respite services with the agency on 5/12/2025. Individual #1 was not informed of their individual rights and the process to report a right's violation upon the start of their respite services. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | The Program Director, Quality Assurance Associate, Program Managers, and Program Specialists have been retrained on the regulation. The individual rights was completed on 7/10/25 and will be completed annually. This was reviewed by licensing personnel. |
12/12/2025
| Implemented |
| 6400.52(c)(6) | Program Specialist #1 did not participate in training to include the implementation of the individual plan for the individuals they work directly with during the 1/1/2024 through 12/31/2024 annual training year. | 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. | HR has been retrained on this regulation. All Program Specialists received annual training on the ISP and will continue annually thereafter. |
12/11/2025
| Implemented |
| 6400.165(f) | Individual #1 is prescribed the following medications to treat symptoms of a diagnosed psychiatric illness: Aripiprazole 5mg tablet for anxiety, Atomoxetine 100mg tablet for ADHD, Buspirone 10mg tablet for anxiety, and Clonidine 0.1mg tablet for anxiety. There is no written protocol to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illnesses. | 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. | The Program Director, Quality Assurance Associate, and Program Specialists have been retrained on the regulation. The SEEP was completed on 12/1/25 and will be completely annually. |
12/12/2025
| Implemented |
| 6400.182(b) | Individual #1 began receiving respite services with the agency on 5/12/2025. The individual exceeded the 31 days of temporary respite care and was fully admitted into the agency on 7/13/2025. Individual #1's initial support plan should have been developed based on the individual assessment no later than 10/11/2025; however, as of 11/25/2025, the individual plan had not yet been developed. | The initial individual plan shall be developed based on the individual assessment within 90 days of the individual's date of admission to the home. | The Program Director, Quality Assurance Associate, and Program Specialists have been retrained on the regulation. An ISP meeting has been tentatively scheduled for 1/13/26. ISP recommendations were sent on 12/8/25 and will be kept on file. |
01/13/2026
| Implemented |