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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.83(a) | Individual #1's Service Plan, last updated 6/25/2026, stated, "[Individual #1] does not have access to knives···". In addition, Individual #1 does not currently have a restrictive procedure plan approved by the human rights team, limiting access to such household sharp utensils. Furthermore, Individual #1's initial and current assessment, completed on 5/11/2026, indicated, "Yes," denoting that Individual #1 uses utensils appropriately as well as knives safely and correctly. However, at 1:35 PM on 7/23/2026, the agency explained that they did not purchase any steak or cooking knives for the home. | A home shall have a kitchen area with a refrigerator, sink, cooking equipment and cabinets for storage. | The agency reviewed Individual #1's current assessment and Service Plan regarding the safe use of knives and household utensils. The assessment indicated that Individual #1 uses utensils appropriately and uses knives safely and correctly, while the Service Plan contained language indicating that Individual #1 did not have access to knives. Individual #1 did not have an approved restrictive procedure limiting access to household sharp utensils.
The discrepancy was corrected, and appropriate kitchen utensils, including knives necessary for normal cooking and meal preparation, were made available in the home consistent with Individual #1's assessed abilities, rights, and current plan. The agency also reviewed the home to ensure the kitchen contained the equipment and household items necessary for normal use.
The Operations Manager and Assistant Director will use the 30-day corrective action period to verify continued implementation and ensure that restrictions are imposed only when supported by the individual's assessed needs, current plan, and applicable approval requirements. |
09/13/2026
| Implemented |
| 6400.113(a) | Individual #1's date-of-admission is 3/16/2026. Individual #1's initial and current fire safety training, completed on 3/16/2026, did not include documented site-specific components relative to the home's evacuation routes and procedures as well as the designated meeting places. Individual #2's current fire safety training, completed on 5/22/2026, did not include documented site-specific components relative to the home's evacuation routes and procedures as well as the designated meeting places. | 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. | Individual #1 and Individual #2 had completed fire safety training; however, the documentation reviewed during the inspection did not include the site-specific components regarding the home's evacuation routes and procedures, and designated meeting place.
The identified deficiency has been corrected. Individual #1 and Individual #2 received documented, site-specific fire safety instruction covering the evacuation routes and procedures for the home and the designated meeting place, as well as the applicable general fire safety requirements.
The agency has revised its fire safety training process to ensure that required fire safety instruction includes and documents both general and site-specific components. |
09/13/2026
| Implemented |
| 6400.181(e)(10) | Individual #1's date-of-admission is 3/16/2026. Individual #1's content-of-records did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | The identified assessment and record deficiencies have been corrected. Individual #1's records were reviewed and updated to include the required lifetime medical history. Individual #2's records were reviewed regarding the applicable psychological evaluation, and the required psychological information or documentation regarding efforts to obtain the applicable evaluation was added to the record.
The Operations Manager and Assistant Director also reviewed the applicable assessment documentation to ensure the identified information was properly incorporated and maintained. |
09/13/2026
| Implemented |
| 6400.181(e)(11) | Neither Individual #2's current assessment, completed on 5/1/2026, nor their content-of-records included an applicable psychological evaluation or documentation attempting to obtain one. | The assessment must include the following information: Psychological evaluations, if applicable. | The identified assessment and record deficiencies have been corrected. Individual #1's records were reviewed and updated to include the required lifetime medical history. Individual #2's records were reviewed regarding the applicable psychological evaluation, and the required psychological information or documentation regarding efforts to obtain the applicable evaluation was added to the record.
The Operations Manager and Assistant Director also reviewed the applicable assessment documentation to ensure the identified information was properly incorporated and maintained. |
09/13/2026
| Implemented |
| 6400.181(e)(12) | Individual #1's initial and current assessment, completed on 5/11/2026, did not include specific areas of training and programming relative for implementation of the recommendations that read, "[Individual #1] needs to continue to improve independence. [Individual #1] should continue to work to identify, establish, and maintain health interpersonal relationships and boundaries." Individual #2's current assessment, completed on 5/1/2026, did not include specific areas of training and programming relative for implementation of the recommendations that read, "[Individual #2] needs to improve [their] behavior at school. [Individual #2] should continue to work to identify, establish, and maintain healthy interpersonal relationships and boundaries." | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The assessments for Individual #1 and Individual #2 were reviewed and revised to address the specific areas of training, programming, and services necessary to implement the recommendations identified in their assessments.
For Individual #1, the assessment was updated to address specific training and programming related to increasing independence and developing and maintaining healthy interpersonal relationships and boundaries. For Individual #2, the assessment was updated to address specific training and programming related to behavioral needs and developing and maintaining healthy interpersonal relationships and boundaries.
The identified deficiencies have been corrected, and the revised information has been incorporated into the applicable records. |
09/13/2026
| Implemented |
| 6400.32(r) | Individual #1's date-of-admission is 3/16/2026. At 11:08 AM on 7/24/2026, Individual #1's bedroom door was not equipped with a locking mechanism. Documentation verifying Individual #1's preferences or wishes of declining a bedroom door lock was not contained within their content of records. On 7/24/2026, Individual #1 was not present during the inspection for an interview to indicate their preferences or wishes regarding a bedroom door lock. | An individual has the right to lock the individual's bedroom door. | The bedroom door deficiency identified during the inspection was corrected on 07/24/2026. A locking mechanism was installed on Individual #1's bedroom door, allowing Individual #1 to exercise their right to lock it.
Although the physical deficiency was corrected immediately, the agency will use the 30-day corrective action period to review bedroom door-locking mechanisms and applicable documentation across its residential locations and implement an enhanced monitoring process to ensure individuals are afforded their rights regarding bedroom door locks. |
09/13/2026
| Implemented |
| 6400.165(f) | Individual #1 is currently prescribed medication to treat symptoms of a diagnosed psychiatric illness. However, Individual #1's content-of-records did not include a written protocol or plan to address the social, emotional, and environmental needs of Individual #1 relative to the symptoms of the psychiatric illness. Individual #2 is currently prescribed medication to treat symptoms of a diagnosed psychiatric illness. However, Individual #2's content-of-records did not include a written protocol or plan to address the social, emotional, and environmental needs of Individual #2 relative to the symptoms of the psychiatric illness. | 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 identified deficiency has been corrected. The agency developed and completed a Social, Emotional, and Environmental Plan (SEEP) for Individual #1 and Individual #2 to address their social, emotional, and environmental needs related to the symptoms of the diagnosed psychiatric illnesses for which medication is prescribed.
As part of the corrective action, the agency also reviewed individuals across its residential programs who are prescribed medication to treat symptoms of a diagnosed psychiatric illness. A SEEP was developed for all applicable individuals receiving psychiatric medications to ensure that the required written protocol is maintained as part of the individual planning process.
The Operations Manager and Assistant Director reviewed the applicable records to verify completion of the SEEPs. Although the identified deficiency has been corrected, the agency will use the 30-day corrective action period to verify implementation of the enhanced monitoring and documentation process. |
09/13/2026
| Implemented |
| 6400.182(c) | Individual #1's Service Plan, last updated 6/25/2026, contained the following discrepancies between their assessment, completed on 5/11/2026, in the following health and safety skill domains: regarding home supervision, Individual #1's Individual Service Plan, last updated 6/25/2026, explained that Individual #1 requires 24-hour, daily supervision with an awake overnight staff. In contrast, Individual #1's assessment, completed on 5/11/2026, informed that Individual #1 can be left unattended in the following home environments for the corresponding amounts of time: their bedroom for up to 60 minutes; the bathroom for up to 30 minutes; and other unspecified areas of the home for up to 30 minutes; and regarding oral hygiene, Individual #1's Service Plan, last updated 6/25/2026, informed that Individual #1 requires verbal prompting to brush their teeth. However, Individual #1's assessment, completed on 5/11/2026, indicated that Individual #1 can independently brush their teeth. Individual #2's Service Plan, last updated 6/24/2026, contained the following discrepancies between their current assessment, completed on 5/1/2026, in the following health and safety skill domains: regarding self-administration medications, Individual #2's Service Plan, last updated 6/24/2026, contained no language or directives on Individual #2's ability to self-administer medications, while Individual #2's assessment, completed on 5/1/2026, informed that Individual #2 cannot self-administer medication and requires aid; regarding fire evacuation, Individual #2's Service Plan, last updated 6/24/2026, stated that "[Individual #2] knows that a fire alarm means there's a fire. [Individual #2's] parents do not know if [Individual #2] would leave when [they] hear a fire alarm, and they do not know if [Individual #2] would leave if [they] see a fire." In contrast, Individual #2's assessment, completed on 5/1/2026, informed that Individual #2 can evacuate the home safely within 2.5 minutes with aid in the form of verbal prompts; regarding water safety, Individual #2's Service Plan, last updated 6/24/2026, explained that "[Individual #2] is safe in a pool [alone], [otherwise], [Individual #2] may try to submerge others in the water." However, Individual #2's assessment, completed on 5/1/2026, indicated that Individual #2 cannot swim in water for at least minute and that Individual #2 is able to remain safe in shallow water but needs supervision and to wear a life vest or floatation device; and regarding home supervision, Individual #2's Individual Service Plan, last updated 6/24/2026, stated that Individual #2 requires 24-hour, daily supervision with an awake overnight staff and a "1:1 staffing [ratio] during transition to ensure [Individual #2] is not eloping or displaying aggression." In contrast, Individual #2's assessment, completed on 5/1/2026, informed that Individual #2 requires a 1:2 staffing ratio from 7 AM to 11 PM and can be left unattended in the following home environments for 30 minutes: their bedroom; the bathroom; and other unspecified areas of the home. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The agency reviewed Individual #1's current assessment and Service Plan regarding the safe use of knives and household utensils. The assessment indicated that Individual #1 uses utensils appropriately and uses knives safely and correctly, while the Service Plan contained language indicating that Individual #1 did not have access to knives. Individual #1 did not have an approved restrictive procedure limiting access to household sharp utensils.
The discrepancy was corrected, and appropriate kitchen utensils, including knives necessary for normal cooking and meal preparation, were made available in the home consistent with Individual #1's assessed abilities, rights, and current plan. The agency also reviewed the home to ensure the kitchen contained the equipment and household items necessary for normal use.
The Operations Manager and Assistant Director will use the 30-day corrective action period to verify continued implementation and ensure that restrictions are imposed only when supported by the individual's assessed needs, current plan, and applicable approval requirements. |
09/13/2026
| Implemented |
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