| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.113(a) | Individual #1 did not have any signed Fire Safety Training on file. | 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. | LSHS admission process did not include a checklist verifying that all required admission documentation was completed and filed, and fire safety instruction was not documented at the time of Individual 1's admission or annually thereafter.
Individual 1 completed general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building, and smoking safety procedures (as applicable), in the individual's primary mode of communication. The signed and dated documentation of this instruction has been placed in Individual 1's record. Attachment#13 |
07/30/2026
| Implemented |
| 6400.141(c)(6) | Individual #1 did not have any TB test on file. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | At the time of the inspection, we did have Individual #1 (TB) on hand. The agency's admission process did not verify that a complete physical examination, including Mantoux tuberculin skin testing, was obtained and filed at admission, and no tracking system existed to identify the missing TB test thereafter. Attachment$14 |
07/30/2026
| Implemented |
| 6400.181(a) | Individual #1 did not have any Initial assessment on file. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential 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 residential home. | The agency's admission process did not include verification that an initial assessment was completed within the required timeframe, and the absence of the assessment was not identified through subsequent record reviews. Attachment#15 |
07/30/2026
| Implemented |
| 6400.217 | Individual #1 did not have any signed Consents on file. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| At the time of the inspection, the agency's admission process did not include obtaining and filing written consent for the release of information, including photographs, and the missing consent documentation was not identified through subsequent record reviews. Written consent for the release of information was reviewed and explained to Individual 1, signed, and placed in the individual's record. Attachment#16 |
07/30/2026
| Implemented |
| 6400.34(a) | Individual #1 did not have any signed Individual Rights statement on file. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | The agency's admission process did not include documented review of individual rights and the process for reporting a rights violation, and the missing documentation was not identified through subsequent record reviews. Individual rights and the process to report a rights violation were informed and explained to Individual 1 and the persons designated by the individual, and the signed and dated rights statement has been placed in the individual's record. Attachment#17 |
07/30/2026
| Implemented |