| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | There were poisons unlocked in the basement of the house. | Poisonous materials shall be kept locked or made inaccessible to individuals. | All poisons in the basement were locked upon licensing representative discovery during the site visit on 10/9/2025. |
10/09/2025
| Implemented |
| 6400.76(a) | The dryer vent was not connected to the back of the dryer. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Upon licensing representative discovery during the 10/9/2025 site visit, facilities received notification and repair dryer vent that day. |
10/09/2025
| Implemented |
| 6400.142(a) | individual #1 had a dental exam on 8/20/24 and then on 9/22/25 which exceeded the annual regulatory timeframe. | 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 #1 had dentals exams completed on 9/17/2024, 9/24/2024, 11/12/2024, and 9/22/2024. Consultations sheets are available for these dates. However, these were not in the program book at the time of the audit. During Assistant Directors' supervision with the site manager, a random chart review will occur to review for documentation compliance. |
11/07/2025
| Implemented |
| 6400.144 | Individual #1's helmet was prescribed in 2022. Since that time there has been no follow up documentation regarding the helmets condition or use. | 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.
The following medications for individual #1 were not on site:
Bactroban 2% ointment.
Lidex Cream
Bacitracin 500-unit PRN.
Blistex lip ointment.
Fleet Enema.
Motrin 100 mgs.
Polysporin ointment PRN.
Tylenol 500 mgs PRN. | Individual #1 had a follow up appointment regarding the helmet on 10/14/2025. |
10/14/2025
| Implemented |
| 6400.181(e)(12) | Recommendations for individual #1 from 2024 to 2025 assessments were identical. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The Residential ID Compliance Director will review documentation submitted by the Program Specialists for compliance. A Microsoft Teams channel has been created for Program Specialists to upload assessments for review. The Residential ID Compliance Director will review submissions and follow up with the Program Specialists as needed to ensure timely and complete compliance |
01/01/2026
| Implemented |
| 6400.181(e)(13)(i) | Individual #1 had extensive dental procedures during this assessment year that were not mentioned under progress and growth for health. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| The Residential ID Compliance Director will review documentation submitted by the Program Specialists for compliance. A Microsoft Teams channel has been created for Program Specialists to upload assessments for review. The Residential ID Compliance Director will review submissions and follow up with the Program Specialists as needed to ensure timely and complete compliance |
01/01/2026
| Implemented |
| 6400.216(a) | There were many records unlocked in the living room of the home. Also, documents with identifying health information for all individuals were on the refrigerator and a corkboard in the kitchen. These included dietary information, lab requests and attendance records. | An individual's records shall be kept locked when unattended.
| All records and identifying health information's were removed from common areas and were locked upon licensing representative discovery during the site visit on 10/9/2025. |
10/09/2025
| Implemented |
| 6400.32(r) | Individual #1 most recent Individual Right's statement did not include the sections R | An individual has the right to lock the individual's bedroom door. | The ID-Residential Director updated the Individual Rights section to include Section R on November 5, 2025. A Microsoft Teams channel has been created to store and maintain all current consent forms for easy access and reference. |
11/05/2025
| Implemented |
| 6400.165(g) | Between the dates of 12/3/2024 and 5/27/25 there was no psychotropic medication review for Individual #1 | 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. | Individual #1 had a Medical Assessment Completed at COMHAR Outpatient on 12/9/2024 and 3/3/2025 which were not in the program book. |
01/01/2026
| Implemented |