| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.101 | On 6/18/2026 at approximately 10:26 AM, there was a turn lock and a deadbolt lock on the exterior of the door, leading from the basement to the garage, and no egress from the garage to the outside of the home. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| On June 23, 2026, the provider notified the property's management of the discovered violation and requested action to bring the property back in compliance. After several follow-up notifications, the provider received notification confirming that the requested repairs will be completed. (see attached) |
06/24/2026
| Implemented |
| 6400.112(c) | The record for the following fire drills did not include problems encountered: 8/07/2025, 9/02/2025, 10/08/2025, 11/12/2025, 12/18/2025, 1/15/2026, 2/11/2026, 3/07/2026, 4/14/2026, and 5/06/2026. | 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. | Upon learning of the discrepancy, the Director of Operations immediately revised the provider's Fire Drill form to include a "problems encountered" column. (see attached) |
06/17/2026
| Implemented |
| 6400.181(e)(4) | Individual #1's assessment, completed 1/05/2026, documents the individual has 30 minutes of unsupervised time at home and the community, and also documents he has a current staffing ratio of 2:1. On 6/17/2026 Program Specialist #1 stated the 2:1 current staffing ratio is incorrect, and he is assessed at 1:2 current staffing ratio. | The assessment must include the following information: The individual's need for supervision.
| Upon learning of the discrepancy, the Program Specialist reviewed and revised the assessment and emailed the revised version to the individual's SC. The alone is correct at 30 minutes, but the staff:individual ratio was transposed. The correction was made and a revision of the assessment was completed. (see attached) |
06/29/2026
| Implemented |
| 6400.181(e)(8) | Individual #1's assessment, completed 1/05/2026, documents the individual can evacuate in the event of a fire with verbal and gestural prompts. Individual #1's individual support plan, last updated 6/12/2026, documents the individual is able to evacuate independently. Program Specialist #1 stated on 6/17/2026 the assessment was incorrect and the individual can evacuate independently. | The assessment must include the following information: The individual's ability to evacuate in the event of a fire. | Upon learning of the discrepancy, the Director of Operations immediately corrected the notification letter and mailed it to the individual's local fire department. (see attached) |
06/17/2026
| Implemented |
| 6400.181(e)(14) | Individual #1's assessment, completed 1/05/2026, does not assess Individual #1's ability to swim. It was left blank. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | Upon learning of the discrepancy, the Program Specialist reviewed and corrected the assessment and emailed the revised version to the individual's SC. (see attached) |
06/29/2026
| Implemented |
| 6400.214(b) | The following records were not in the home for Individual #1: current dental examination, current assessment, and current physical examination. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| Upon learning of the discrepancy, the Program Coordinator pulled up the documents on her laptop, however, the inspector did not review them at that time. Upon the arrival of the Director of Operations, the documents were immediately printed. |
06/18/2026
| Implemented |
| 6400.169(a) | Direct Service Worker #2 had documentation of initial medication administration training completed 5/24/2023 and no annual practicum since. Direct Service Worker #3 scored 88.92% on the initial medication administration training examination 2/20/2025 and did not pass the course. Both staff have passed medications and are not currently trained in medication administration. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | Direct Service Worker #2 in fact was in compliance during his initial employment with the agency and did have all required practicums prior to his departure from the agency on 2/14/2024. He had a practicum and MAR review November 2023 and would have been due for his annual in May 2024 however he departed prior to that date. The paperwork associated with his initial employment, original medication paperwork and annual practicums was requested by and provided to the inspector for review. To correct the indicated violation, both Direct Service Worker #2 and Direct Service Worker #3 were enrolled and successfully completed a department-approved medications administration course (as evidenced by the attached documentation below). |
07/01/2026
| Implemented |