| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | A trash bag was found underneath the bathroom sink next to the trashcan. The bag was soiled with a feces or vomit-like substance. | Clean and sanitary conditions shall be maintained in the home. | Health1st LLC immediately removed and appropriately disposed of the soiled trash bag. Staff were re-educated that bodily-fluid-contaminated waste must be promptly removed and disposed of in accordance with applicable infection-control, sanitation, and safety requirements |
08/24/2026
| Implemented |
| 6400.67(a) | A kitchen drawer to the right of the refrigerator was unsecured and could fall out completely when opened. | Floors, walls, ceilings and other surfaces shall be in good repair. | Health1st LLC immediately secured the kitchen drawer to prevent it from falling out when opened and to eliminate the identified safety hazard. The drawer and surrounding area were inspected to verify that the drawer was secure, stable, and functioning properly. |
08/24/2026
| Implemented |
| 6400.70 | During inspection, the landline telephone was inoperable. Staff reported that it occurred 'last night'; a work order was not provided. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| Health1st LLC promptly addressed the inoperable landline telephone and restored telephone service. The telephone had been damaged shortly before the inspection. Staff had reported the damage to the surveyors and were reminded of the importance of promptly reporting any telephone malfunction, documenting the issue, and initiating corrective action to ensure continued access to a working telephone. |
08/24/2026
| Implemented |
| 6400.72(b) | The closet door in Individual #2's bedroom was off track, and the cabinet was damaged and in need of replacing; a work order reflecting the noted areas were assessed was not provided. | Screens, windows and doors shall be in good repair. | Health1st LLC promptly addressed the identified maintenance and safety concerns. Individual #2 has a history of recurrent property damage and had recently damaged the closet door and cabinet in the bedroom. The closet door was repaired and properly repositioned, and the damaged cabinet was repaired to ensure the area was safe and functional. Staff were re-educated on the importance of promptly reporting, documenting, and following up on household maintenance and safety concerns. |
08/24/2026
| Implemented |
| 6400.112(e) | The home opened in December 2025, and an asleep drill was not held until June 2026, which exceeds the maximum regulatory timeframe of at least one (1) asleep drill every six (6) months. | A fire drill shall be held during sleeping hours at least every 6 months. | Health1st LLC reviewed the home's fire safety drill schedule and confirmed that the next asleep fire drill is scheduled to occur within six months of the previous asleep drill. The Program Manager or designee reviewed the applicable regulatory requirements regarding the timely completion and documentation of asleep fire drills.
The next asleep fire drill is scheduled for October 2026, which is within four months of the previous asleep drill. Staff were re-educated regarding the required frequency, timely completion, and documentation requirements for all fire safety drills. |
08/24/2026
| Implemented |
| 6400.181(f) | Records for Individual #2 reflected that the 06/20/2026 Annual Assessment was provided to individual plan team members on 08/11/2026, which was after the 06/23/2026 ISP Meeting was held. The assessment is required to be shared with team members at least 30 calendar days prior to the individual plan meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Health1st LLC reviewed the Annual Assessment process and the applicable regulatory requirement that completed assessments be provided to individual plan team members at least 30 calendar days before the ISP meeting. The Program Manager or designee reviewed this requirement and process with applicable staff and implemented a tracking system to help ensure that Annual Assessments are completed and distributed within the required timeframe. |
08/24/2026
| Implemented |