| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.103 | Documentation notes that furnace inspections were completed on 6/30/24 and 8/2/25. This extends beyond the annual time frame. | Furnaces shall be cleaned at least annually. Written documentation of the cleaning shall be kept. | On 8/2/25, Furnace inspection was completed. As of 9/3/2025, the annual service date is recorded on the agency calendar to ensure that the furnaces are serviced on time. |
09/03/2025
| Implemented |
| 6500.121(c)(14) | The physical dated 10/30/24 for Individual #1 did not include medical information pertinent to diagnosis and treatment in case of an emergency. The section assigned for the information was blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | On 8/27/2025, management had a meeting concerning the medical visit form requirements. Our focus was based on the clarification of required fields on the medical visit forms and implementation of steps for proper completion of medical visit. |
08/27/2025
| Implemented |
| 6500.34(a) | Documentation of annual review of Individual Rights for Individual #1 were dated as completed on 11/10/23 and 1/27/25. This is outside of the required annual time frame. | Individual rights and the process to report a rights violation shall be explained to the individual, and persons designated by the individual prior to moving into the home and annually thereafter. | On 8/27/2025, management had a meeting concerning completion of annual review of Individual Rights and complying with the requirements. |
08/27/2025
| Implemented |
| 6500.151(a) | The assessment dated 11/18/24 was not sufficiently updated to reflect the progress and growth for Individual #1. Several sections noted the exact information from the prior year that was not currently accurate. Assessments must be updated with accurate information each year. Assessments cannot be completed simply to meet the regulatory or programmatic requirements. Providers must develop assessments that are meaningful, accurate, and useful. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the 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 home. | As of 9/27/2025, all assessments will be accurately updated to reflect individual progress and growth while fully meeting all regulatory requirements. |
09/27/2025
| Implemented |