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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(e)(1) | Individual #1 was assessed on 1/6/25 to not be able to manage their own funds. The individual does receive $50.00 on a regular basis from the rep-pay. The individual is given complete control of the monies with no agency interventions/monitoring, despite the assessment indicating the individual can manage $0.00 money. On 6/18/25, there was no financial ledger kept at the home for Individual #1's financial resources, including the dates and amounts of deposits and withdrawals as well as any corresponding receipts. | 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 June 18, 2025, it was identified that Individual #1, who was assessed on January 6, 2025, as unable to manage their own funds, receives $50.00 monthly. However, financial transaction records were not being kept in accordance with the regulation. Upon review, it was determined that the individual is, in fact, capable of managing their own funds, and the current assessment does not accurately reflect this.
On July 2 , 2025, a review meeting was held with Individual #1 and the support team to reassess financial capability.
The team determined that Individual #1 is able to manage their own funds independently.
The individual's Assessment and Individual Support Plan (ISP) are being reviewed to accurately reflect their ability to independently manage their monthly funds.
The updated assessment will be completed
The Supports Coordinator will be contacted to revise the ISP to reflect Individual #1 is capable of managing her own funds.
The Program Specialist will be retrained on :
The importance of accurately documenting individuals¿ capabilities.
Ensuring that assessments and ISPs are person-centered and reflect current functioning |
07/31/2025
| Implemented |
| 6400.65 | On 6/18/25 at 12:02 pm the only bathroom in the basement was without a window or proper ventilation. [Repeat Violation-7/1/24 et al.] | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| On June 18, 2025, during a licensing audit, it was observed that the only bathroom located in the basement did not have a window or an operable mechanical ventilation system.
Immediate Corrective Action Taken:
A licensed contractor was hired, and installation of a code-compliant mechanical ventilation system (bathroom exhaust fan vented to the outside) was completed on June 25, 2025.
The exhaust fan is hardwired with the light switch to ensure it operates during bathroom use.
Retraining of all House Supervisors and Program Specialist will be conducted to review 6400.65 requirements and the importance of environmental safety standards. |
07/31/2025
| Implemented |
| 6400.141(b) | Individual #1's annual physical examination, dated 10/1/24, was not dated by the physician. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | During a licensing audit, it was found that Individual #1's annual physical exam, dated October 1, 2024, was not dated by the physician, resulting in noncompliance with the regulation.
Correction Plan
1. Immediate Corrective Action Taken:
On June 18 ,2025, the original physical exam form was returned (faxed) to the physician's office for completion.
The physician dated the form on July 18, 2025 and faxed back to the provider's office. The dated copy was placed in Individual #1's medical file.
House Managers and Program Specialist will be trained on the importance of regulatory compliance of 6400.141(b) and documentation standards as well as the Physical exam checklist. |
07/31/2025
| Implemented |
| 6400.181(d) | Individual #1 assessment dated 1/6/24 was not signed by a program specialist. | The program specialist shall sign and date the assessment. | During a licensing review, it was found that Individual #1's assessment dated January 6, 2024, was not signed by the program specialist, resulting in noncompliance of regulation 6400.181(d).
Immediate Corrective Action:
The program specialist originally conducting the assessment from 1/6/25 is no longer employed by the provider agency. The current Program Specialist will review the assessment completed on January 6, 2024 for accuracy and completion and signed and dates the document.
The signed assessment was refiled in the individual's record and sent via email to the team.
A Individual Assessment Checklist will be used to ensure all required components including the program specialist's signature and date are completed before filing. |
07/31/2025
| Implemented |
| 6400.181(e)(1) | Individual #1's assessment dated 1/6/25 did not identify strengths, needs and preferences. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | During a licensing inspection, it was identified that Individual #1¿s assessment dated January 6, 2025, did not include documentation of the individual's strengths, needs, and preferences, in violation of the regulatory requirement.
The program specialist will meet with Individual #1, to gather accurate and current information regarding the individual's strengths, functional needs, and personal preferences.
A revised assessment will be completed and signed, and now includes a clearly defined section outlining strengths, needs, and preferences as required.
Long-Term Corrective Action:
A review of all current assessments will be conducted, to ensure that the required elements under 6400.181(e)(1) were properly documented for all individuals.
Any assessments found to be lacking will be corrected immediately with updated input from the individual and their support team.
Program specialists will be retrained regarding assessment content requirements under 6400.181(e) and person-centered planning practices |
07/31/2025
| Implemented |
| 6400.32(n) | On 6/18/25 at 11:50 am the only house telephone was located in the staff office, which is locked, at times. the individual residing at the home does not have a restrictive procedure plan approved by a human rights team, limiting the right to unrestricted and private access to telecommunications. | An individual has the right to unrestricted and private access to telecommunications. | On June 18, 2025, during a licensing inspection, it was noted that the only house phone was located in the staff office, which is locked at times, thereby restricting individuals¿ access to a telephone.
Immediate Corrective Action Taken:
On June 20, 2025, a second phone was placed in the common area in the home ( Livingroom) where it is readily accessible to individual at all times and allows for private use.
Individual was informed new location of the phone and encouraged to use it freely.
The House Supervisor and all House staff will be retrained , on individual rights under 6400.32(n), with emphasis on privacy, dignity, and accessibility. |
07/31/2025
| Implemented |
| 6400.165(b) | The individual is prescribed Aripiprazole 30 Mg Tablets to be taken at 8PM for mental health. This medication was not in the home, as it was placed "on hold" and was not administered from 6/14/25 to 6/17/25, due to an expired script. The agency did not provide the current physician's orders, and the prescribed medication, itself, was not at the home due to the physician's orders not being kept current. | A prescription order shall be kept current. | During a licensing inspection, it was identified that Individual #1, who is prescribed Aripiprazole 30 mg daily at 8:00 PM for mental health treatment, did not receive the medication from June 14, 2025, through June 17, 2025. The lapse in administration occurred because the prescription expired and the doctor's office did not respond to refill requests, despite multiple follow-up attempts made by both the pharmacy and provider staff beginning 7 days prior to the expiration date.
On June 19, 2025, after continued attempts, the provider and pharmacy escalated the issue by contacting the medical office's on-call physician .
A new prescription was received and filled on June 26, 2025, and medication administration resumed immediately.
A Medication Escalation Protocol was implemented on June 30, 2025, outlining the following steps::
Escalation Procedure
1. Initiate prescription renewal request 10 days prior to expiration.
2. Contact the prescriber¿s office via phone or fax. Document the request in the Medication Communication Log.
3. If no response within 48 hours, initiate the first follow-up:
o Call the prescriber¿s office again.
o Send a second written fax request, marked URGENT.
4. If still no response after another 48 hours (96 hours total):
o Contact the office manager or practice administrator.
o Leave a message or request a callback from the on-call or backup physician.
5. Notify the Program Specialist and Program Director immediately after 4 days of no response.
6. If unresolved within 5 days of the initial request:
o Call the individual¿s Primary Care Provider or psychiatrist (if different).
o Contact the pharmacy to explore emergency refill options or alternate plans.
7. Document every communication attempt in the Medication Communication Log including:
o Date, time, who was contacted, summary, and staff initials.
8. Once the prescription is received and filled:
o Resume administration.
o Complete a Medication Error Report if any dose was missed.
o Finalize the log with the prescriber¿s instructions and resolution date.
House Supervisors were trained on the escalation process, documentation standards, and their responsibilities to act proactively when responses are delayed. |
07/18/2025
| Implemented |
| 6400.165(g) | Individual #1 had a psychotropic medication review on 8/28/24 and not again until 1/21/25 exceeding the three-month requirement. | 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. | During a licensing inspection, it was determined that Individual #1, who is prescribed a psychotropic medication, had a medication review on August 28, 2024, and not again until January 21, 2025, exceeding the required three-month interval. The delay occurred because the individual refused video appointments and requested in-person visits, but the previous provider was unable to accommodate this. The first available appointment with a new provider was January 21, 2025.
The individual was scheduled with a new provider who offers in-person appointments, and a psychotropic medication review was successfully completed on January 21, 2025.
The individua's support plan and assessment will be updated , to reflect their preference for in-person psychiatric appointments only.
House Supervisor and Program Specialist will be retrained on 6400.165(g) ,The importance of timely psychotropic reviews, respecting individual choice while maintaining regulatory compliance, escalating concerns when provider delays impact compliance. |
07/31/2025
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | On 5/14/23, at 8:13PM Individual #1 was near the refrigerator in the kitchen in the home. Direct Service Worker #1 was engaged in her cell phone while sitting on the couch in the living room of the home. Individual #1 and Direct Service Worker #1 began a verbal exchange and then Individual #1 approached Direct Service Worker #1. Individual #1 made two attempts to take Direct Service Worker #1's cell phone. Direct Service Worker #1 stood up and a physical altercation between Individual #1 and Direct Service Worker #1 ensued, lasting approximately 3 minutes. The physical altercation involved Direct Service Worker #1 pushing Individual #1 to the floor, grabbing Individual #1 by the shirt and hair and throwing an object at Individual #1. At approximately, 8:16PM, Direct Service Worker #1 departed the living room to the porch in the front of the home and interacted with a neighbor. Emergency Services were contacted, and the Police and an ambulance arrived at the home. Medical care was not provided to Individual #1. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | 5/14/2023 , a physical altercation between Individual #1 and Direct Support Worker #1 ensued lasting approximately 3 minutes. The Direct Support worker #1 engaged with Individual #1 instead of separating from the situation. HNA recognizes the need for more extensive training for the staff
On 6/20/2023, all Direct Support Workers, supporting individual#1 will receive, Safe Crisis Management training. This training will be instructed by the Program Specialist. This training will be tailored to Individual #1
Prevention: Utilizing the proactive strategies, recognizing triggers and conditions as presented in Individual #1' s behavior support plan. De-escalation: How to properly respond to an individual in crisis by utilizing active listening skills, voice tone , body language and non-verbal cues. Management of the Crisis: strategies on dealing with the crisis ( changing task, possible removing the trigger, bargaining/negotiation) utilizing coping skills.
Recognizing the Cycle of Escalation: Knowing the individuals baseline behaviors, what are the stress responses that trigger behavior, bring the individual back to baseline after behavior. after successfully completing the 6 hour course, students will receive a certificate of completion for their training files. |
10/31/2023
| Implemented |
| 6400.80(b) | A six feet long by six-inch wide section of outdoor siding, on the driveway side of the home, was loose and protruding from outside wall of the home posing a free falling hazard. The retaining wall on the driveway side of the home was haphazardly stacked with varying size, rough edged, bricks and rocks, had vegetation growing through and leaning presenting a free falling and laceration hazards. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The outside of the building and the yard shall be well maintained, in good repair and free from unsafe conditions.
A 6 foot by 6 inch piece of outdoor siding, on the driveway side of the home was loose and could pose a free-falling risk due to a recent inclement weather. HNA's contractor was immediately contacted, and the outside 6 foot 6 inch piece of siding was repaired on 5/22/2023 and no longer a free-falling hazard. The retaining wall on the driveway side of the home was haphazardly stacked with varying size, rough edged rocks and bricks, had vegetation growing through areas and leaning presenting a free falling and laceration hazard. HNA's landscaping contractor was contacted immediately and construction on a new Versa Lok wall was scheduled to be installed on 7/12/2023.
The monthly site audit form was amended on page 7, Section 9 Outside, to reflect the inspection of all retaining walls to assure the wall / s are in good condition, as well as siding, gutters, rainspouts, sofit and facia are in good condition and not a free-falling hazard. |
06/30/2023
| Implemented |
| 6400.51(b)(5) | Direct Service Worker #1, date of hire 10/25/22 was not trained on Individual #1's Behavior Support Plan prior to working with Individual #1. | The orientation must encompass the following areas: Job-related knowledge and skills. | HNA recognizes, Direct Service Worker #1 was not trained on Individual #1's Behavior Support Plan prior to working with Individual #1. On 5/19/2023 ,the House Manager immediately began to re-train the Direct Support Workers , working with Individual #1 on Individual #1's Behavior Support Plan . All DSWs working with Individual #1 were re-trained and completed a sign off sheet by 5/31/2023.The House Manager will onboard All Direct Service Workers prior to working with Individual #1 on Individual #1's " Getting to Know Me " book which encompasses Individual #1's ISP, Behavior Support Plan and synopsis of individual #1's like, dislikes, and needs. On going Training of individual #1's staff will consist of :The Behavior Specialist attending one house meeting every quarter. to review the Behavior Supports Plan and any changes made to the plan. As well as discuss any concerns from staff . |
07/01/2023
| Implemented |
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