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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The dishwasher has a buildup of stains, and grime. The cabinet doors on the island are dirty with spills and need to be cleaned. The cover on the trash bin in the kitchen is dirty. The kitchen wall has spills and spots, the base board underneath it is also covered with spills and other buildup of dust. The space between the washer and dryer has a buildup of dirt and debris. | Clean and sanitary conditions shall be maintained in the home. | King Family Enterprise's review determined that existing quality assurance, environmental monitoring, and physical site inspection processes were not sufficiently detailed to identify and address developing concerns prior to the licensing inspection. Specifically, environmental inspections and housekeeping oversight did not include standardized cleaning expectations or monitoring tools to ensure consistent sanitation throughout the residence. Although routine cleaning activities occurred, staff did not have a detailed cleaning checklist identifying expectations for appliances, utility areas, baseboards, walls, cabinets, and other high-touch surfaces.
A thorough deep cleaning and sanitization of the residence, including the dishwasher, utility areas, baseboards, and other identified surfaces, was completed on June 10, 2026. To prevent recurrence, by June 30, 2026, KFE will implement a detailed daily environmental cleaning checklist and revise environmental inspection procedures to include room-by-room sanitation standards (See attached Environmental Inspection Checklist, Physical Site Inspection Form, and related housekeeping procedures). Direct Support Professionals and supervisory personnel will receive re-education regarding housekeeping expectations, environmental cleanliness requirements, and documentation procedures. Weekly site inspections will be conducted by the Program Specialist to verify completion of cleaning tasks and identify sanitation concerns requiring immediate corrective action.
By June 30, 2026, KFE will establish a Physical Site Inspection Binder and Maintenance Tracking Log for each residential location. The log will document identified concerns, responsible parties, corrective actions, completion dates, and verification of corrective action completion. Physical site conditions, environmental concerns, medication-related concerns, and outstanding repairs will be reviewed during weekly management meetings and monitored through KFE's Quality Management process to identify trends and ensure timely resolution of concerns. |
06/10/2026
| Implemented |
| 6400.68(b) | The water temperature in the bathroom that individual #1 uses read at 138.7 degrees, which exceeds the maximum limit of 120 degrees. Must be addressed within 24 hours | Hot water temperatures in bathtubs and showers may not exceed 120°F. | KFE's review determined that there was no formal process for routine monitoring and documentation of water temperatures to ensure compliance with Chapter 6400 requirements. As a result, elevated water temperatures were not identified and addressed prior to the licensing inspection.
On 5/30/26, an Antiscald adapter was added to each shower head, which shuts off water to a trickle before scalding occurs. The valve was installed to safely regulate and lower the water temperature to below 120°F.
To ensure that the Water temperature does not exceed the maximum limit of 120 degrees, a log will be filled out daily by staff using an independent thermometer (See attached Water Temperature Monitoring Log and revised Physical Site Inspection Procedures; See attached Water Temperature Monitoring Procedure). Any reading that exceeds the maximum limit of 120 degrees will be addressed within 24 hours. The water log will be reviewed weekly by the Program Specialist and monthly by the Quality Assurance Coordinator. In addition, King Family Enterprise will use the Connecteam management software app and enable instant alerts to management of any urgent temperature concerns. |
05/30/2026
| Implemented |
| 6400.71 | There are no emergency numbers posted by the telephone. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| King Family Enterprise's review determined that physical site inspection procedures did not include verification of required emergency postings during routine inspections. As a result, required emergency telephone numbers were not identified as missing prior to the licensing inspection. Emergency numbers (hospital, police, fire, ambulance, and poison control) were printed in large font and posted adjacent to all facility telephones on June 1, 2026. To prevent recurrence, by June 30, 2026, KFE will revise physical site inspection procedures to require verification of all required emergency postings during weekly site inspections. Direct Support Professionals and supervisory personnel will receive re-education regarding physical site requirements and emergency preparedness standards. Emergency postings will be incorporated into the Physical Site Inspection Binder and Physical Site Inspection Checklist (See attached Physical Site Inspection Checklist and Physical Site Inspection Procedures). |
06/01/2026
| Implemented |
| 6400.76(a) | The sliding door at the entrance of the apartment is off track and cannot slide | Furniture and equipment shall be nonhazardous, clean and sturdy. | King Family Enterprise's review determined that existing quality assurance, physical site inspection, and maintenance monitoring processes were not sufficiently detailed to identify and address concerns prior to the licensing inspection. Specifically, physical site inspection procedures did not adequately identify, document, communicate, and track maintenance concerns requiring repair. Additionally, communication between Direct Support Professionals responsible for daily observation of the residence and supervisory personnel responsible for maintenance oversight was inconsistent. The specific hazardous or damaged sliding door was immediately repaired, cleaned or replaced to ensure full resident safety. A Physical Site Inspection was completed on 6/10/26. To prevent recurrence, by June 30, 2026, KFE will revise physical site inspection procedures to require documentation, reporting, and tracking of maintenance concerns identified during daily operations and routine inspections (See attached Physical Site Inspection Procedure, Maintenance Tracking Log, and Physical Site Inspection Binder tools). Direct Support Professionals and supervisory personnel will receive re-education regarding maintenance reporting responsibilities, documentation requirements, and timelines for corrective action. Weekly physical site inspections will be conducted by the Program Specialist, and all identified maintenance concerns will be entered into the Physical Site Inspection Binder, Maintenance Tracking Log, and Connecteam tracking system for timely resolution.
By June 30, 2026, KFE will establish a Physical Site Inspection Binder and Maintenance Tracking Log for each residential location. The log will document identified concerns, responsible parties, corrective actions, completion dates, and verification of corrective action completion. KFE will also utilize Connecteam as an electronic maintenance tracking system to document repair requests, assign responsibility, monitor completion timelines, and provide notification to supervisory personnel regarding outstanding maintenance concerns. Physical site conditions, environmental concerns, medication-related concerns, and outstanding repairs will be reviewed during weekly management meetings and monitored through KFE's Quality Management process to identify trends and ensure timely resolution of concerns. |
06/10/2026
| Implemented |
| 6400.141(c)(10) | Individual #1's physical dated 03/02/26 does not specify if the individual has a communicable disease or not. | 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. | King Family Enterprise determined that this violation occurred because medical documentation review procedures did not include a standardized process for verifying the completeness of physical examination documentation prior to filing. As a result, the physical examination dated March 2, 2026 did not identify whether the individual had a communicable disease, and the omission was not identified during record review. The individual attended a follow-up appointment on June 12, 2026 to obtain the required information. To prevent recurrence, by June 30, 2026, KFE will revise medical records review procedures to require verification of all required components of physical examinations prior to filing (See attached Medical Records Review Procedure and Physical Examination Verification Checklist). Staff accompanying individuals to medical appointments will receive re-education regarding documentation review requirements. The Program Specialist and Licensed Nurse will review all physical examinations upon receipt to ensure completeness and compliance with Chapter 6400 requirements. |
06/12/2026
| Implemented |
| 6400.151(a) | Staff member #1's- physical expired 05/02/26 and the new physical is dated 05/13/26. There is no grace period. | 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. | King Family Enterprise determined that this violation occurred because employee credential tracking and supervisory monitoring processes did not adequately identify upcoming expiration dates for required employee health documentation. As a result, Staff #1's physical examination expired on May 2, 2026, and was not renewed until May 13, 2026. The employee completed an updated physical examination on May 13, 2026.
To prevent recurrence, by June 30, 2026, KFE will revise employee credential tracking procedures to include advance notification of upcoming expirations and monthly personnel file reviews. Supervisory personnel responsible for personnel file oversight will receive re-education regarding Chapter 6400 employee qualification requirements and documentation standards. KFE will implement a credential tracking system to monitor expiration dates for employee physicals, trainings, clearances, and other required documentation (See attached Employee Credential Tracking Tool and Personnel Records Monitoring Procedure) |
05/13/2026
| Implemented |
| 6400.24 | PRN Medication Promethazine DM was listed on the MAR, but no available in the home at time of inspection | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | King Family Enterprise determined that this violation occurred because medication inventory monitoring procedures were not consistently followed and there was no formal process requiring staff to notify supervisory personnel when PRN medications reached reorder thresholds. As a result, the PRN medication was depleted before a refill was requested. The missing PRN medication Promethazine DM was refilled on May 28, 2026. To prevent recurrence, by June 30, 2026, KFE will revise medication inventory monitoring procedures to establish medication reorder thresholds and require weekly medication inventory reviews (see attached revised medication administration and medication monitoring procedures). Medication Administration Certified staff, Direct Support Professionals, and supervisory personnel will receive re-education regarding medication inventory monitoring, refill procedures, and documentation requirements. Weekly medication inventory reviews will be conducted and documented by the Program Specialist to ensure all prescribed and PRN medications listed on the MAR remain available in the residence. KFE 's licensed nurse will participate in monthly medication reviews and assist with oversight of medication administration and medication record documentation to ensure compliance with Chapter 6400 medication requirements. |
05/28/2026
| Implemented |
| 6400.165(g) | There are no psychotropic medication reviews since 04/03/25 for individual #1. Psychotropic med review must be completed every 3 months. | 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. | King Family Enterprise determined that this violation occurred because medication monitoring procedures did not include a system for tracking due dates for quarterly psychotropic medication reviews. As a result, the required psychotropic medication review was not obtained within the required timeframe following the review completed on April 3, 2025.
To correct the violation, the Program Specialist will coordinate with the prescribing physician and interdisciplinary team to obtain an updated psychotropic medication review. The updated psychotropic medication review was obtained on 6/15/26. By June 30, 2026, KFE will revise medication monitoring procedures to include tracking of psychotropic medication review due dates and required follow-up appointments (See attached Psychotropic Medication Monitoring Procedure and Medication Review Tracking Log). The Program Specialist, Licensed Nurse, and Medication Administration Certified staff will receive re-education regarding psychotropic medication monitoring requirements and documentation standards. |
06/15/2026
| Implemented |
| 6400.166(a)(11) | There is no purpose or diagnosis listed on the MAR and / or prescription labels | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | King Family Enterprise determined that this violation occurred because there was no standardized verification process to ensure that all required medication information, including diagnosis or purpose, was documented on the Medication Administration Record prior to implementation. As a result, the medication was transcribed onto the MAR without verification that the diagnosis or purpose was included. The diagnosis and purpose for the medication were obtained from the prescribing physician and added to the MAR on June 1, 2026 (see attached MAR). To prevent recurrence, by June 30, 2026, KFE will revise medication documentation procedures to require verification of all physician orders and MAR entries prior to implementation (see attached revised Medication Administration procedures and MAR Verification process). Medication Administration Certified staff, Direct Support Professionals responsible for medication administration, and supervisory personnel will receive re-education regarding MAR documentation requirements and medication record verification procedures. Monthly medication audits will be conducted to verify that all medications include the diagnosis or purpose as required. KFE 's licensed nurse will participate in monthly medication reviews and assist with oversight of medication administration and medication record documentation to ensure compliance with Chapter 6400 medication requirements. |
06/01/2026
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The inside of the oven had baked in grease and grime. | Clean and sanitary conditions shall be maintained in the home. | Quality Assurance Staff began conducting weekly physical site inspections of each residence effective June 1, 2025 (see attached). The QA or Residential Supervisor will document all findings, including minor and major deficiencies. Then Immediately report any urgent health or safety concerns to the Program Specialist and the President/CEO. The Program Specialist will Conduct comprehensive monthly inspections of all residential sites. Review and verify the weekly inspection records from the . Track recurring issues or trends and report findings to the President/CEO during the monthly Quality Review Meeting. Along with the Training coordinator the Quality Assurance staff will provide coaching or re-training to direct support staff where deficiencies are identified. All trainings will be documented on the training sign in sheet/certificate in accordance with 6400 regulations. Ensure corrective action is implemented for deficiencies within 48 hours. Oven was cleaned of the grease and grime (SEE ATTACHED) |
06/01/2025
| Implemented |
| 6400.82(f) | Individual #1's bathroom did not have a trash receptacle. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Quality Assurance Staff began conducting weekly physical site inspections of each residence effective June 1, 2025 (see attached). The QA or Residential Supervisor will document all findings, including minor and major deficiencies. Then Immediately report any urgent health or safety concerns to the Program Specialist and the President/CEO. The Program Specialist will Conduct comprehensive monthly inspections of all residential sites. Review and verify the weekly inspection records from the . Track recurring issues or trends and report findings to the President/CEO during the monthly Quality Review Meeting. Along with the Training coordinator the Quality Assurance staff will provide coaching or re-training to direct support staff where deficiencies are identified. All trainings will be documented on the training sign in sheet/certificate in accordance with 6400 regulations. Ensure corrective action is implemented for deficiencies within 48 hours. Trash can replaced (SEE ATTACHED) |
06/01/2025
| Implemented |
| 6400.113(a) | No fire safety training was available at time of review for individual #1. | 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. | A new fire drill was conducted on 5/6 by Qusonia Edwards (Supervisor) and Dionne Edwards, and all signatures of staff are included. Documentation has been completed and retained (see attached). All staff at the home were immediately notified of the citation (insert when and how) and the importance of ensuring evacuation occurs within the regulatory timeframe. All staff were also made aware that incomplete fire drills are not accepted. Quality Assurance will review all fire drills monthly to ensure they are completed and documented accurately. If the issue persist staff will receive disciplinary action including up to termination. Individual #1 received Training (SEE ATTACHED) |
05/06/2025
| Implemented |
| 6400.141(a) | Individual #1's annual physical dated 4/11/25 was past the regulatory 1-year time period since the previous one was dated 3/28/24. The exam date 4/11/25 was also blank. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | King Family Enterprise was able to set up an appointment for individual # 1 however the individual refused to go (SEE ATTACHED). King Family Enterprise was able to reschedule the appointment for 6/30?25. King Family Enterprise will continue to support individual #1 with care and respect with a goal to attend all of his physical as per the ODP 6400 Regulations. |
06/30/2025
| Implemented |
| 6400.144 | Ibuprofen PRN was on the MAR but was not in with individual #1's medications. | 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.
| King Family Enterprise reviewed the current Medication Administration policy and have added a procedure that will assure close monitoring of all Medication including PRN provided for the Health and Safety of the Individual. Which will include tracking and managing of all Medication to ensure the Health and Safety of the individual according to ODP 6400 Regulations. Program specialist refilled the Ibuprophen medication. |
06/06/2025
| Implemented |
| 6400.151(a) | Staff #1 did not have a physical in the record. | 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. | King Family will ensure that every employee that works outside of the commonwealth will be required to submit a FBI criminal background check at the time of being hired. King Family Enterprise is using their current Document checklist is being used by Erika Murchison (Staff Development), Kathering Rodgriuez (Aministrator Assistant) & Barbar King (CFO) which is used to assure the complaints with 6400.21(b). During the review we noticed the Staff had his physical in the file. |
06/02/2025
| Implemented |
| 6400.181(a) | Individual #1's last assessment was dated 1/8/2024 | 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. | King family enterprise will ensure that the Annual Assessment is completed. Dionne Davies completed the Assessment on 5/5/25. |
05/05/2025
| Implemented |
| 6400.163(h) | The medication, Senna Docusate tab, was in with individual #1's medications, but was not on the MAR. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | King Family Enterprise recognize that the Medication Administration Policy will give us the process that is needed to give our individuals the a high level of care. The Team reviewed the MAR and updated the MAR as needed. |
05/06/2025
| Implemented |
| 6400.166(a)(7) | The name of the prescriber of the medications for individual #1 was not on the MAR. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | King Family Enterprise recognize that the Medication Administration Policy will give us the process that is needed to give our individuals the a high level of care. The Team reviewed the MAR and updated the MAR as needed. The prescribers were added to the MAR (SEE ATTACHED) |
05/05/2025
| Implemented |
| 6400.181(f) | There is no documentation that the assessment for individual #1 was sent to the team 30 days prior to the individual plan meeting at the time of review | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | King Family Enterprise will ensure that an assessment is sent to the Team 30 days prior to the meeting. |
06/02/2025
| Implemented |
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