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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.63(a) | On 9/23/2026 at 11:07 AM, the hot water temperature measured at 123.4 degree Fahrenheit at the sink in the bathroom. | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | On 9/23/2026, the hot water tank temperature was turned down. On 9/24/2026, the water temperature was retested at 115.6 degrees Fahrenheit in the bathroom shower and 114.9 at the kitchen sink. |
10/12/2026
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(e)(1) | The agency assumes the responsibility of maintaining Individual #1's financial resources, acting as their representative payee. On 11/6/24, the agency provided nine receipts, spanning from 8/14/24 to 9/25/24, for purchases greater than $15. However, there were no ledgers or expense records kept for those months, including November 2024 as well, to ensure all purchases greater than $15 had been accounted for. Therefore, receipts for purchases made by staff on behalf of Individual #1 or expense records for purchases greater than $15 have not been provided in a sufficient manner in order to measure compliance. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. | On 11/13/2024, the agency implemented procedures to track individuals' expenses/transactions, including receipts, in addition to the current procedure individuals use to take out cash on hand. |
11/13/2024
| Implemented |
| 6400.212(b) | The agency provided Individual #1's monthly Tracking Expense Sheet on 11/6/24. On the following dates, 8-11-24, 10-2-24, 10-2, 24, 10-9-22, entries were erased using white out making the original entries not legible. | Entries in an individual's record shall be legible, dated and signed by the person making the entry.
| The agency identified by initialing the mentioned entries above that whiteout was used, mistakenly, by the Operations Coordinator. |
11/07/2024
| Implemented |
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