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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.113(a) | Individual #1 moved into the home on 4/1/25. Individual #1 did not have fire safety training completed until November 2025. | 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. | Upon identification that Individual #1 did not receive fire safety training upon admission, corrective action was taken. Individual #1 completed fire safety training in November 2025. The training included general fire safety, evacuation procedures, responsibilities during fire drills, and the designate. CRHS reviewed admission procedures to ensure required fire safety instruction is completed upon admission. |
01/06/2026
| Implemented |
| 6400.211(b)(2) | Individual #1 did not have emergency information that included the name, address, telephone number, and relationship of a designated person to be contacted in case of emergency. | Emergency information for each individual shall include the following: The name, address and telephone number of the individual's physician or source of health care. | Upon identification that Individual #1's emergency information was incomplete, corrective action was taken. The required emergency contact information, including the name, address, telephone number, and relationship of the designated emergency contact, was obtained and placed in the individual's record. The emergency information was reviewed to ensure it is complete and accessible via a Facesheet. |
02/04/2026
| Implemented |
| 6400.165(g) | Individual #1 had a review of medications to treat symptoms of psychiatric illness on 4/22/25, 6/2/25, 7/8/25 and 8/4/25. Documentation of these medication reviews does not include the diagnosis that the medication is prescribed to treat. | 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. | Corrective action included immediate conversations with all treating psychiatrists regarding documentation requirements. Individual #1's medication review records were updated to include the diagnosis being treated, the reason for prescribing the medication, the need for continued use, and the prescribed dosage, in accordance with regulatory requirements. The individual's record was reviewed to ensure documentation is complete and current. |
01/12/2026
| Implemented |
| 6400.182(c) | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. Individual #1's individual plan is not developed based upon a current assessment. Individual #1's initial assessment dated 4/10/25 contains multiple areas of information that is not consistent with the information contained in Individual #1's Individual Service Plan dated 4/11/25 and last updated 1/5/26. Areas of inconsistency include supervision, financial management, the individual's ability to care for personal hygiene needs, home care, self-medicating, ability to use a computer, internet, etc, financial management skills, bathing skills, home management skills, First aid/emergency response skills, personal interactions, recreation, and personal adjustment. Individual #1's assessment also identifies an individual who does not reside in Individual #1's home as the individual being assessed. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Upon identification that Individual #1's Individual Service Plan (ISP) was not developed based upon a current and accurate assessment, immediate corrective action was taken. Individual #1's assessment and ISP were reviewed in full. A corrected, current assessment specific to Individual #1 was completed to accurately reflect the individual's needs, abilities, supervision requirements, skill levels, and supports, including but not limited to personal hygiene, home management, financial management, medication administration, use of technology, personal interactions, recreation, and emergency response skills. The corrected assessment has been forwarded over to the team so that, Individual #1's ISP can be revised if necessary to ensure consistency with the assessment and to accurately reflect the individual's current needs and services. Documentation of the updated assessment has been placed in the individual's record. |
02/06/2026
| Implemented |
| 6400.213(1)(i) | Individual #1's individual record did not contain a current dated photo. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Upon identification that Individual #1's record did not contain a current dated photograph, corrective action was taken. A current dated photograph of Individual #1 was obtained and placed in the individual's record via a completed Facesheet. The record was reviewed to ensure required personal information is complete. |
02/06/2026
| Implemented |
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