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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(e)(1) | Individual #1's Service Plan, last updated 6/4/25, indicates that "[they] require assistance with money management and budgeting." Individual #1's current assessment, completed on 1/17/25, provided a "Score of 1," meaning that they require total guidance with money management. Therefore, the agency assumes the responsibility of maintaining Individual #1's financial resources. 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. | During the licensing audit on June 17, 2025, it was identified that Individual #1¿s most recent service plan, updated on June 4, 2025, states the individual requires assistance with money management and budgeting. The individual's assessment, dated January 17, 2025, supports this need with a score of 1, indicating that Individual #1 requires total guidance and supervision in managing funds.
Despite these documented needs, no money ledger or financial tracking tool was present in the home. This is a violation of § 6400.186, which requires that services and supports identified in the service plan must be implemented as written. The absence of a ledger for an individual requiring full financial assistance represents a failure to carry out this support, impeding accountability and posing a risk to the individual's financial well-being.
Corrective Action Taken
the Program Specialist created a personal money management ledger for Individual #1 to ensure all financial activity is accurately tracked at the home.
It was clarified and documented that:
All of Individual #1's funds are sent directly to the agency office by the representative payee.
Funds are then signed out by the House Supervisor as needed and brought to the home for use.
House Supervisors are required to document all expenditures and transactions in the new ledger kept in the home.
House Supervisor will be e retrained on:
Proper use of the newly implemented money ledger
Documentation of withdrawals signed out by the House Supervisor
Their responsibilities in ensuring supports listed in the service plan are followed
Handling representative payee funds
Agency financial tracking expectations
Compliance with 6400.186 and related financial documentation procedures |
07/31/2025
| Implemented |
| 6400.64(d) | On 6/18/25, at 10:34 AM, in the full bathroom located in the bedroom hallway on the home's main level, there was an uncovered plastic, white dish-soaking bin with a crumpled-up paper towel and a plunger with a garbage bag wrapped around its plunging end. Individual #1's current restrictive procedure plan, last updated 1/30/25, restricts the use of trash receptacles in bathrooms. However, this uncovered plastic, white dish-soaking bin appeared to be a modification of this restriction. | Trash in the bathroom, dining and kitchen areas shall be kept in cleanable receptacles that prevent the penetration of insects and rodents. | During the licensing inspection on June 18, 2025, a violation of § 6400.64(d) was cited when the bathroom was found to contain a bin holding a plunger in a plastic bag and a crumpled paper towel. This posed a sanitation concern and was in direct conflict with Individual #1's restrictive plan, which prohibits any trash receptacles in the bathroom due to known behavioral risks (e.g., inappropriate disposal or handling of trash).
Immediate Corrective Action:
The bin and its contents were immediately removed from the bathroom.
The area was disinfected, and the plunger was stored appropriately in a locked utility closet, away from the individual's access.
A full review of Individual #1¿s restrictive plan was conducted with all staff to reinforce compliance and awareness.
All staff in the home received immediate re-training on:
The specifics of Individual #1's restrictive plan
Sanitation and safe storage procedures
Importance of adhering to behavioral and safety restrictions |
07/31/2025
| Implemented |
| 6400.101 | On 6/18/25, at 10:22 AM, the interior basement door leading to the attached garage was equipped with a pop lock on the inside and a push-pinhole locking system on the garage side, requiring a bobby pin, paper clip, ink pen cartridge, or similar object to disengage it from the garage. The attached garage does not have an exterior swing door to prevent entrapment. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| During the licensing inspection on 6/18/2025, it was observed that the interior basement door leading to the attached garage was equipped with a push pin hole with an interior pop lock which required a bobby pin to disengage from the garage side. This configuration restricts immediate egress in the event of an emergency and is not compliant with 6400.101.
Immediate Corrective Action Taken:
On 06/25/2025, the lock was immediately removed and replaced with a keyed lock on the garage side and a turn latch on the interior side., allowing free and immediate egress.
All residents and staff were notified of the door change, and a full walkthrough was conducted to ensure no other egress pathways were obstructed or locked improperly. |
07/31/2025
| Implemented |
| 6400.105 | On 6/18/25, at 10:27 AM, in the laundry room of the home's game room, the gas dryer was situated directly to the left of the gas water heater, making actual contact. | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| On June 18, 2025, during an on-site inspection, it was observed that the gas dryer in the laundry room was in direct contact with the gas water heater, which creates a fire hazard and violates spacing requirements for combustible equipment.
On June 20, 2025, immediately following the identification of the hazard, the gas dryer was moved to maintain the required clearance from the gas water heater, in compliance with the manufacturer's and local code requirements. |
07/31/2025
| Implemented |
| 6400.113(a) | Individual #1was trained 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 on 3/7/24, and then again on 5/14/25. This exceeds the annual requirement. | 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. | During the licensing audit conducted on June 17, 2025, it was identified that Individual #1 received general fire safety training, including evacuation procedures and responsibilities during fire drills, on March 7, 2024, and then again on May 14, 2025. This results in a time span of over 14 months between the two trainings.
Per § 6400.113(a), each individual shall be trained annually in general fire safety, evacuation procedures, and their role during fire drills. The training must occur no more than 365 days apart. The late completion of the second training constitutes noncompliance with the required annual fire safety training schedule.
Corrective Action Taken:
Upon identification of the violation, the Program Specialist immediately reviewed the fire safety training records for the individual.
While Individual #1 did receive updated fire safety training on May 14, 2025, the team acknowledged it occurred beyond the required 12-month timeframe.
A corrective action meeting was held with the Program Specialist, Residential Supervisor responsible for coordinating annual individual trainings.
Program Specialist and Residential Supervisors were retrained on the requirements of 6400.113(a) and the process for tracking and documenting fire safety training dates. |
07/31/2025
| Implemented |
| 6400.141(c)(3) | Individual #1's current physical examination, completed on 8/30/24, did not include their immunizations, as the corresponding field read, "See attached." However, there was no such documentation attached to this physical examination. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | During a licensing audit conducted on June 18, 2025, it was identified that Individual #1's physical examination dated August 30, 2024, did not contain documentation of immunizations. The physical form included the notation "see attached," but no immunization documentation was actually attached to the physical, resulting in non-compliance with the regulation.
The immunization record was immediately attached to the existing physical examination form dated August 30, 2024.
A new standardized Annual Physical Examination Form was developed that includes clearly marked fields for immunization documentation and eliminates vague references such as 'see attached.'
House Supervisors and Program Specialists will be retrained on the use of the new Annual Physical Examination Form and on the specific requirements of 6400.141(c)(3). |
07/31/2025
| Implemented |
| 6400.141(c)(7) | Individual #1 did not have documentation of a gynecological examination including a breast examination and a Pap test. Individual #1 is 18 years of age or older. | 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. | During a licensing audit conducted on June 18, 2025, it was identified that Individual #1 did not have documentation of a gynecological examination, including a breast examination and Pap test, as required by the regulation. The individual¿s record lacked any valid form or provider documentation reflecting this exam.
An appointment was scheduled for Individual #1 to receive a comprehensive gynecological examination, including a breast exam and Pap test, in accordance with physician recommendation.
A new standardized Gynecologic Examination Form was developed and adopted to ensure future exams meet regulatory and documentation standards. |
07/31/2025
| Implemented |
| 6400.142(d) | Individual #1 had dental examinations completed on 11/14/24, and then again on 5/29/25. However, Individual #1's dental examination completed on 11/14/24, did not include documentation that a teeth cleaning or the checking of gums and dentures was performed. | The dental examination shall include teeth cleaning or checking gums and dentures. | During a licensing audit conducted on June 18, 2025, it was identified that Individual #1¿s dental examination completed on November 14, 2024, did not include documentation confirming that a teeth cleaning and gum check had been performed. The record only included a general note that a periodic exam occurred, with no specific details on gum or teeth evaluation.
Upon follow-up with the dental provider, it was verified that a complete dental cleaning and gum evaluation were performed on 11/14/2024. However, this was not clearly documented in the individual¿s file.
Immediate Corrective Action Taken:
On June 20, 2025, the Operations Manager contacted the dental provider and obtained written verification that the periodic examination ,included cleaning and gum check and was performed during the 11/14/2024 exam.
The updated dental record was immediately placed in Individual #1's file to correct the documentation gap
Program Specialists and House Supervisors were retrained on ODP Regulation 6400.142(d)
How to review dental documents to verify inclusion of required elements and how to follow up with dental providers when documentation is unclear or incomplete.
The training included instructions on using the new checklist and verifying it prior to final record submission. |
07/31/2025
| Implemented |
| 6400.142(f) | Individual #1's current assessment, completed on 1/17/25, provided a "Score of 3," indicating that they require verbal instruction to complete oral hygiene. Individual #1 had dental hygiene plans written on 5/10/24 and then re-written again on 6/2/25. This exceeds the annual requirement. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | During a licensing audit conducted on June 18, 2025, it was identified that Individual #1 had an oral hygiene plan developed on January 17, 2025, following a dental score of 3 indicating a need for verbal prompts. However, the same plan was duplicated again on May 10, 2025, and June 2, 2025, exceeding the annual requirement for oral hygiene plans as outlined in 6400.142(f).
Immediate Corrective Action Taken:
The additional oral hygiene plans dated May 10 and June 2, 2025, were reviewed and archived. It was verified that no clinical changes occurred that would have warranted a new or revised plan.
The plan dated January 17, 2025 remains the official and active oral hygiene plan for Individual #1.
Notes were added to the individual's record clarifying that the additional plans were created in error and are not valid revisions.
Program Specialists and House Supervisors will be retrained on ODP regulation 6400.142(f), with a focus on proper frequency and criteria for oral hygiene plan development.
A new Oral Hygiene Plan Review Form was introduced, requiring:
Verification of the last plan date
Documentation of clinical justification if a new plan is warranted before the annual renewal
Staff were instructed to record any minor changes in individual status or support in progress notes, rather than creating new plans. |
07/31/2025
| Implemented |
| 6400.181(e)(1) | Individual #1's current assessment, completed on 1/17/25, did not include their functional strengths, needs, and preferences. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | During a licensing review conducted on06/17/2025, it was noted that Individual #1's assessment, developed on 1/17/25, did not include documentation of the individual's strengths, needs, or preferences, in violation of § 6400.181(e)(1). This omission limited the effectiveness and completeness of the individual's person-centered plan.
1. Immediate Corrective Action Taken:
On 07/21/2025, the Program Specialist met with Individual #1 to gather and document their:
Personal strengths (e.g., communication skills, hobbies, social connections),
Functional support needs (e.g., ADL assistance, mobility, supervision),
Personal preferences (e.g., routines, food choices, privacy).
The assessment was updated on 07/18/2025 to include this information and reissued to the individual's team, including the Supports Coordinator, for review.
The corrected assessment was added to Individual #1's file
Program Specialists will be retrained on the regulatory requirements for assessments, including best practices for capturing strengths and person-centered preferences. |
07/31/2025
| Implemented |
| 6400.181(e)(3)(i) | Individual #1's assessment, completed on 1/17/24, was utilized for Individual #1's last Service Plan Annual Review Meeting that was held on 9/18/24. Therefore, since Individual #1's assessment, completed on 1/17/24, was greater than six months old at the time that their Service Plan Annual Review Meeting had been held on 9/18/24, individual #1's current level of progress and performance in the following areas were not reflected: (i) acquisition of functional skills; (ii) communication; (iii) personal adjustment; and (iv) personal needs with or without assistance from others. | The assessment must include the following information: The individual's current level of performance and progress in the following areas: Acquisition of functional skills. | During the licensing inspection conducted on June 17, 2025, it was found that the assessment used for Individual #1 at their annual Individual Support Plan (ISP) review meeting on September 18, 2024, was outdated. The assessment had been completed on January 17, 2024, which is more than six months prior to the annual review meeting.
According to 6400.181(e)(3)(i), the assessment must include a current level of progress and performance in functional skills such as acquisition, communication, personal adjustment, and personal needs, with or without assistance. Because the assessment was older than six months, it did not reflect current abilities or progress, making it noncompliant.
The individual's progress in acquiring new functional skills, communication development, independence in meeting personal needs, and ability to adjust socially and emotionally may have been misrepresented.
The planning team did not have current, accurate data to inform service decisions, potentially affecting the quality and appropriateness of supports provided.
The Program Specialist completed a new comprehensive assessment for Individual #1 to reflect their current levels of progress and functioning in:
Acquisition of functional skills
Communication abilities
Personal adjustment and coping skills
Personal care needs, with or without assistance
The Program Specialist will submit the updated assessment for 2025 for the 9/25 annual review meeting.
Program Specialist will complete a targeted training on:
Regulation 6400.181(e)(3)(i)
Timeframe for assessment completion prior to ISP meetings
Best practices for documenting current functioning across all required domains |
07/31/2025
| Implemented |
| 6400.182(c) | Individual #1's Service Plan, last updated 6/4/25, contained the following discrepancies between their current assessment, completed on 1/17/25, in the following health and safety skill domains: regarding community supervision, Individual #1's Service Plan, last updated 6/4/25, stated that "[Individual #1] must be supervised at all times in the community to ensure [their] health and safety" and that "staff will remain within arm's length at all times in the community" and "when crossing streets." However, Individual #1's current assessment, completed on 1/17/25, provided a "Score of 3," meaning that individual #1 requires verbal instruction around traffic. In addition, Individual #1's current assessment, completed on 1/17/25, indicated, "Yes," to the corresponding field that "[Individual #1] requires additional staff support when in the community," but did not specify the number of additional staff needed; and regarding water safety, Individual #1's Service Plan, last updated 6/4/25, stated that "[Individual #1] know how to swim," while their current assessment, completed on 1/17/25, provided a "Score of 2," indicating that Individual #1 requires partial guidance in the forms of gestural or physical prompting to swim. Furthermore, Individual #1's Service Plan, last updated 6/4/25, contained no reference to or language addressing their knowledge of water safety, while their current assessment, completed on 1/17/25, provided a "Score of 2," indicating that Individual #1 requires partial guidance in the forms of gestural or physical prompting to understand water safety. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | During the licensing inspection conducted on June 17, 2025, it was identified that Individual #1's most recent service plan, updated on June 4, 2025, did not accurately reflect the individual¿s current abilities and support needs as outlined in the assessment completed on January 17, 2025, which is a violation of 6400.182(c).
Corrective Action Taken:
The Program Specialist will conduct a side-by-side review of the individual's assessment dated 1/17/2025 and service plan dated 6/4/2025.
The Program Specialist¿s findings will be reviewed with the interdisciplinary team, including supervisory staff and the Supports Coordinator.
The Supports Coordinator will be prompted to revise the service plan to reflect accurate and current information from the assessment, specifically in the domains of:
Community supervision
Traffic and behavioral safety
Water safety
The Program Specialist will document the review findings and follow up with the Supports Coordinator to ensure that all revisions are completed and signed by the appropriate team members.
All Program Specialists will complete a training on 6400.182(c) .
Training will focus on ensuring consistency between assessments and service plans, especially in the domains of supervision, behavior, and health/safety. |
07/31/2025
| Implemented |
| 6400.186 | Individual #1's Service Plan, last updated 6/4/25, indicates that "[they] require assistance with money management and budgeting." Individual #1's current assessment, completed on 1/17/25, provided a "Score of 1," meaning that they require total guidance with money management. 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. Therefore, since the agency assumes the responsibility of maintaining Individual #1's financial resources, and without record of a financial ledger and receipts of corresponding transactions, comprehensive assistance and accountability with those transactions is not being provided to Individual #1. Individual #1's Service Plan, last updated 6/4/25, explains that although Individual #1 can safely use and avoid poisonous materials, "they are kept locked in the home due to concerns [that] [Individual #1] could use them to assault staff." At 10:25 AM on 6/18/25, on an open, accessible shelf in the laundry room located in the home's game room, there were the following unlocked cleaners: a 32-fluid-ounce bottle of True Living Drain Cleaner; a 24-fluid-ounce bottle of Clorox Toilet Bowl Cleaner; two 28-fluid-ounce bottles of Lysol Mult-Surface Concentrated Cleaner; a 32-fluid-ounce spray bottle of True Living Glass Cleaner; and a 1.43-pint bottle of Mr. Clean Multi-Surface Cleaner. Therefore, Individual #1's Service Plan, last updated 6/4/25, was not implemented as written. | The home shall implement the individual plan, including revisions. | During the licensing audit on June 18, 2025, it was identified that components of Individual #1¿s Individual Support Plan (ISP) were not being implemented as written, which constitutes a violation of § 6400.186. This regulation requires that all services and supports identified in the individual plan must be delivered in accordance with the plan to ensure the individual's health, safety, and independence.
The specific area(s) of noncompliance included:
Money Management and Poisonous materials.
This failure may result in a reduction of support effectiveness, hinder individual progress, and compromise the individual¿s right to person-centered planning and care.
Corrective Action Taken:
The Program Specialist conducted a full review of Individual #1's ISP
Any discrepancies between the ISP and what was being implemented in practice were flagged and resolved with staff re-training and supervisory guidance.
all poisonous materials (cleaning supplies, disinfectants, etc.) were relocated to a locked cabinet in the basement.
The cabinet remains locked at all times, and keys are accessible only to authorized staff.
A visual inventory list was created and posted inside the locked cabinet for accountability.
all Direct Support Professionals (DSPs) supporting Individual #1 received retraining on:
Understanding and implementing ISP supports
Daily documentation procedures |
07/31/2025
| Implemented |
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