| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | Poisons must be stored in their original labeled containers. At the time of the inspection, located on the landing inside the front door of the home was a blue 5-gallon plastic bucket filled approximately ¼ of the way full white crystals that appeared to be some kind of ice or rock melt. It wasn't possible to determine if the crystals were toxic or non-toxic since they were not in the original labeled container. In the lower level of the home, located on top of the dryer was a clear 2 drawer Rubbermaid container and the top drawer was full of what appeared to be plastic pods that had 3 liquid compartments (1 liquid compartment was white, 1 was purple, and one was blue). The pods appeared to be laundry detergent pods. When the Licensing Representative inquired about the pods, the agency staff went into the storage area and brought a sealed/unopened package of Members Mark 65 pack laundry power packs single dose laundry detergent, and the photo on the bag resembled the pods in the drawer on top of the dryer. | Poisonous materials shall be stored in their original, labeled containers. | Upon identification, the ice-melt material was immediately removed and properly disposed of. A new bag of ice melt was purchased and brought to the home. The new product was kept in its original labeled container and placed inside the bucket for stability and accessibility while remaining in the manufacturer's packaging. The laundry detergent pods were removed from the unsecured drawer and disposed of. There was already a new bag of laundry pods at the house in it's original container available for use. |
02/26/2026
| Implemented |
| 6400.68(b) | At the time of the inspection, the water in the main bathroom's shower/bathtub measured 123.4°F. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Immediately upon notification that the water temperature was too high during the inspection, staff adjusted the water heater thermostat to reduce the hot water temperature. After adjustment, the water temperature was rechecked and measured at 111°F, which is within the acceptable and safe range. |
02/26/2026
| Implemented |
| 6400.141(c)(7) | A gynecological examination, including a breast examination including a breast examination and a Pap test for women 18 years of age or older. Individual #1 had a gynecological examination on 1/8/25 with a pap test, however the form did not include documentation of a breast examination being completed for Individual #1. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | It was confirmed that the breast exam was offered at the time of the gynecology appointment; however, the individual declined the exam. The refusal was documented in the individual's medical record. Staff reviewed the importance of preventive screenings with the individual in a respectful and supportive manner. The individual has a physical examination scheduled for 3/20/26. At that time, staff will request that the provider conduct a breast exam as part of the scheduled visit, pending the individual's consent. The outcome of the exam will be documented accordingly. |
02/26/2026
| Implemented |
| 6400.151(a) | A staff person shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Staff #1's date of hire is 8/19/25, and Staff #1's physical was dated 8/24/25 by the physician which was after their date of hire. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Administrative staff including the Vice President & Administrative Assistant will ensure that all newly hired employees complete and submit documentation of a required physical examination prior to their first day of employment. No employee will be permitted to begin work until the physical examination documentation is received and verified. |
03/02/2026
| Implemented |
| 6400.151(c)(2) | Staff #1's date of hire is 8/19/25, and they had a negative Tuberculin skin testing by Mantoux Test completed on 8/24/25 which was after their date of hire. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | Administrative staff including the Vice President & Administrative Assistant will ensure that all newly hired employees complete and submit documentation of a completed TB Test prior to their first day of employment. No employee will be permitted to begin work until the TB Test documentation is received and verified. |
03/02/2026
| Implemented |
| 6400.181(e)(13)(i) | Individual 1's assessment dated 12/10/25 under the health section did not discuss that Individual #1's 3/18/25 physical examination which noted their diet recommendation to a heart healthy, low carb/sugar diet. Individual #1's Individual Support Plan (ISP) last updated 01/23/2026, states under the meals/eating status section that Individual #1 is prescribed a diabetic diet. The agency did not properly update the health level of Individual #1 in their assessment as it related to their current diet recommendation at their 3/18/25 physical examination. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| Upon identification of the discrepancy, the Program Specialist immediately reviewed the individual's physical, Assessment, and ISP for accuracy. The Assessment was updated to reflect the dietary recommendation outlined in the 3/25 physical examination (heart-healthy, low carbohydrate/sugar diet). Notification was sent to the Supports Coordinator requesting that the ISP be updated to ensure consistency with the physician's documented dietary recommendation. |
03/03/2026
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medications to treat the symptoms of a diagnosed psychiatric illness and had a medication review on 8/26/25, then the next one occurred on 12/18/25 which exceeds the 3-month timeframe required by this regulation. | 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. | Upon review of records, it was confirmed that an appointment had been scheduled within the required three-month timeframe on 10/7/25; however, the individual refused to attend the appointment. A refusal form was completed and placed in the individual's record. Following the refusal, staff rescheduled the appointment, and the individual was seen on 12/18/25. |
02/26/2026
| Implemented |
| 6400.182(c) | Individual #1's Individual Support Plan (ISP) last updated on 01/23/2026 stated under the Supervision Care Needs section, Home Supervision, number of hours of supervision 23. On 11/5/24, Individual #1 was granted 60 mins of alone time in her home. This is primarily so she is not interrupted when her roommate wants to quickly go to the store. Individual #1 will be left an emergency contact list and staff will inform her what to do in case of emergency before they leave. Community supervision, number of hours of supervision, 23. Individual #1 has up to 30 mins of alone time in the community to go on walks to de-escalate herself. After the 30 min limit is up, she requires supervision. Individual #1's assessment dated 12/10/25 stated under the supervision needs that Individual #1 requires indirect supervision (staff on premises) while in the home. She has 2 hours of alone time in her home and 2 hours in the community to use as she chooses. Individual #1 can be alone in any room of the home with staff on premises. Individual #1 should be within earshot of staff in the community, unless she is using unsupervised time. Individual #1 can be left unattended in a vehicle with the keys removed while the vehicle is within line of sight. The ISP and assessment do not match.
Individual #1's ISP states under the learning/cognition section that Individual #1 would not be able to manage /budget her own money. However, Individual #1's assessment dated 12/10/25, under the financial independence section states that Individual #1 can differentiate between denominations of money. She independently handles her spending money. Individual #1 does not want staff to assist with her finances or SNAP card and she chooses to handle it independently. Support staff will assist her when she is in need of making larger purchases that require receipts to be turned in to her repayee. The ISP and assessment do not match as it related to Individual #1's financial management/independence. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Upon identification of the discrepancy, the Program Specialist immediately conducted a comprehensive review of the individual's Assessment to verify the accuracy of documented supervision needs and financial management abilities. Notification was sent to the Supports Coordinator requesting that the ISP be revised to ensure alignment with the updated Assessment. This action was taken to ensure consistency and accuracy between the Assessment and the ISP. |
03/03/2026
| Implemented |