| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | Individual #1's initial and current assessment, completed on 7/23/2025, indicated that Individual #1 requires total assistance with managing money and that Individual #1 needs verbal prompting to recognize monetary values. The last documented deposit to the home made by Individual #1's representative payee occurred on 3/21/2026, in the amount of $300 cash. On 6/17/2026, Individual #1's June 2026 financial ledger reflected the following transactions: a debit of $5.00 for Individual #1's day program on 6/11/2026 with a remaining balance of $71.00 and a debit of $10.00 for Individual #1's day program on 6/15/2026 with an ending balance of $11.00. However, Individual #1's cash-on-hand at the home totaled $68.01. [Repeated Violation---6/17/25, et al.] | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | 6400.22(d)(1) - The home shall keep an up-to-date financial and property record for each individual that includes the following: 1. Personal possessions and funds received by or deposited with the family or home.
The House Manager was retrained on the proper maintenance of financial ledgers, including the accurate and timely documentation of all transactions, receipts, expenditures, and balances. Emphasis was placed on ensuring that ledger records are complete, current, and supported by appropriate documentation. |
06/30/2026
| Implemented |
| 6400.22(d)(2) | Individual #1's initial and current assessment, completed on 7/23/2025, indicated that Individual #1 requires total assistance with managing money and that Individual #1 needs verbal prompting to recognize monetary values. The last documented deposit to the home made by Individual #1's representative payee occurred on 3/21/2026, in the amount of $300 cash. On 6/17/2026, Individual #1's June 2026 financial ledger reflected the following transactions: a debit of $5.00 for Individual #1's day program on 6/11/2026 with a remaining balance of $71.00 and a debit of $10.00 for Individual #1's day program on 6/15/2026 with an ending balance of $11.00. However, Individual #1's cash-on-hand at the home totaled $68.01. [Repeated Violation---6/17/25, et al.] | (2) Disbursements made to or for the individual.
| 6400.22(d)(2) -- The home shall keep an up-to-date financial and property record for each individual that includes the following:
(2) Disbursements made to or for the individual.
The House Manager was retrained on the proper procedures for disbursing funds to individuals, including the use of a receipt book designated specifically for that individual. A receipt will be completed each time funds are disbursed, documenting the amount, date, and recipient of acknowledgment. All receipts will be maintained on file in accordance with agency policy and recordkeeping requirements. A receipt book was purchased and was put in the individual's personal lock box. |
06/30/2026
| Implemented |
| 6400.66 | At 10:44 AM on 6/17/2026, the exterior lighting fixture located on the deck at the rear of the home was inoperable, and there was no other sufficient light source nearby. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| 6400.66 - Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
It was identified that lighting in an outside area of the home was not functioning properly, resulting in inadequate illumination. Upon discovery, the light fixture/bulb was replaced, and proper lighting was restored immediately. The House Manager completed a walkthrough of the home to verify that all rooms, hallways, stairways, exits, and exterior access areas were adequately illuminated and free from safety concerns. Documentation of the repair was maintained in the home's maintenance records. |
06/30/2026
| Implemented |
| 6400.68(a) | At 10:50 AM on 6/17/2026, the hot water temperature at the kitchen sink measured 122.3 degrees Fahrenheit. At 11:03 AM, the hot water temperature at the sink in Individual #1's bedroom ensuite half-bathroom measured 125.4 degrees Fahrenheit. | A home shall have hot and cold running water under pressure. | 6400.68(a) - A home shall have hot and cold running water under pressure.
The water temperature was immediately adjusted to ensure safe and appropriate hot and cold running water in the home. Staff were instructed on proper water temperature guidelines in accordance with the agency water temperature policy. Water temperatures will be monitored daily to ensure compliance and safety for all individuals served. The Program Specialist will continue to monitor water temperatures on a monthly basis during the site audit to ensure ongoing compliance with regulatory and agency standards.
agency water temperature policy. |
06/30/2026
| Implemented |
| 6400.101 | At 11:18 AM on 6/17/2026, the interior door leading to the home's attached garage was equipped with both a standard door lock assembly and deadbolt, requiring a key to disengage them from the garage side. Since the attached garage did not have an exterior swing door, an entrapment area existed within this area. [Repeated Violation---6/17/25, et al.] | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| 6400.101- Stairways, halls, doorways, and exits from rooms and from the building shall be unobstructed.
POC: The doorknobs were inadvertently installed with the key side being in the garage. All doorknobs will be re-installed to have the key side in the basement. |
06/25/2026
| Implemented |
| 6400.181(e)(1) | Individual #1's initial and current assessment, completed on 7/23/2025, did not address their functional strengths, needs, and preferences, as the document neither included corresponding fields, nor contained such information throughout its entirety. [Repeated Violation---6/17/25, et al.] | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | 6400.181(e)(1)_-- The assessment must include functional strengths, needs and preferences of the individual.
A section was added to the annual assessment to document each individual's functional strengths, needs, and preferences.
On 6/26/26 the Program Specialist revised the assessment dated 7/23/2025 to reflect the functional strengths, needs and preferences of individual #1 and resent to the supports coordinator. |
06/26/2026
| Implemented |
| 6400.181(e)(12) | Individual #1's initial and current assessment, completed on 7/23/2025, did not include specific areas of training, programming, and services as there were neither corresponding fields, nor such information contained elsewhere in the document. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | 6400.181(e)(12)- - The assessment must include the following information:
Recommendations for specific areas of training, programming, and services.
The agency has reinforced procedures requiring that all individual assessments include documented recommendations, and that follow-up actions are clearly recorded in the individual's record.
The Operations Manager will provide targeted training to the Program Specialist(s) on:
· Completing and reviewing individual assessments
· Identifying and documenting recommendations
· Ensuring recommendations are translated into actionable supports and services
· Tracking completion and outcomes of recommendations within required timeframes
On 6/26/26 the Program Specialist revised the assessment dated 7/23/2025 to reflect the recommendations for training, programming and services for individual #1 and resent to the supports coordinator. |
06/26/2026
| Implemented |
| 6400.181(e)(14) | Individual #1's initial and current assessment, completed on 7/23/2025, did not address their ability to swim, as the document contained contradictory information as follows: Under "Section B: Safety Skills," the corresponding skill criterion read: "Ability to swim: Yes or No," with a "Yes" response indicated; however, under the "Safety Skills Section:" a narrative explained that "[Individual #1] cannot swim independently. [Individual #1] needs supervision." | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | 6400.181(e)(14)- - The assessment must include the following information: 14. The individual's knowledge of water safety and ability to swim.
The agency reinforced procedures for completing and implementing all ISP/assessment requirements.
The Operations Manager will provide targeted training to the Program Specialist on
- - Understand requirements of ISP and assessment implementation
On 6/26/26 the Program Specialist revised the assessment dated 7/23/2025 to reflect individual#1 's knowledge of water safety and the ability to swim. and resent to the supports coordinator. |
06/26/2026
| Implemented |
| 6400.32(h) | At 10:48 AM on 6/17/2026, the home was equipped with cameras installed in the living room, dining room, staff office, and game room. However, Individual #1's content of records did not include documentation demonstrating that Individual #1 had provided their consent to the following: the use of cameras in the home's common areas and staff office as well as their intended purpose; the type of feed (visual and/or audio) that the home's cameras capture; the identification of those who can access the feed and/or recordings; and the length of time for which any captured recordings are stored. | An individual has the right to privacy of person and possessions. | 6400.32(h) - An individual has the right to privacy of person and possessions.
Upon discovery of missing documentation, the program specialist obtained the individual's signature for consent which occurred on 6-17-2026. |
06/17/2026
| Implemented |
| 6400.46(b) | Direct Service Worker #1's fire safety training, completed on 3/1/2026, did not include home or site-specific content in relation to evacuation routes, fire extinguisher locations, and designated meeting places. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | 6400.46(b)- Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).
The agency has developed a standardized annual fire safety training program specific to the In-Home and Community Support component. This training encompasses both computerized training and in-home residential fire safety training.
DWS #1 was retrained on 6/25/2026 on the in home portion of the fire safety training by the Training Specialist.
A training tracking system will be utilized to monitor annual training due dates and provide advance notifications prior to expiration |
06/25/2026
| Implemented |
| 6400.182(c) | Individual #1's Service Plan, last updated 5/26/2026, and their initial/ current assessment, completed on 7/23/2025, contained discrepancies in the following health and safety skills domains: regarding non-insulated heat sources exceeding 120 degrees Fahrenheit, Individual #1's Service Plan, last updated 5/26/2026, indicated that Individual #1 is safe around such heat sources. In contrast, Individual #1's assessment, completed on 7/23/2025, indicates that Individual #1 requires partial physical and/or gestural prompting to understand the dangers of such heat sources as well as to sense and quickly move away from them; regarding fire evacuation, Individual #1's Service Plan, last updated 5/26/2026, contained no information or directives on Individual #1's ability to evacuate the home in the event of a fire and stated, "[Individual #1] participates in fire drills at both of [their] day programs. [Individual #1] received [their] initial fire safety training on 10/31/2025. [Individual #1's] residential home practices fire drills/fire safety monthly, and the most recent fire drill was held on 1/6/2026." However, Individual #1's assessment, completed on 7/23/2025, indicates that Individual #1 can independently evacuate the home in the event of a fire; and regarding community supervision, Individual #1's Service Plan, last updated 5/26/2026, stated that Individual #1 "will generally look both ways before crossing a street." In contrast, Individual #1's assessment, completed on 7/23/2025, indicates that Individual #1 requires partial physical and gestural prompting to negotiate traffic areas. [Repeated Violation---6/17/25, et al.] | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | 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.
The Program Specialist was retrained on the procedures for notifying the Supports Coordinator of any necessary changes to an individual's service needs that may require revisions to the Individual Support Plan (ISP). The Program Specialist was also retrained on documenting all notifications, communications, and corresponding actions taken in accordance with agency policy.
on 6/26/2026 the Program Specialist reviewed bot the assessment and the ISP noting the discrepancies in the health and safety domains and will arrange a meeting with the Supports Coordinator to address. |
06/25/2026
| Implemented |