| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.77(b) | At the time of inspection, neither a thermometer nor a pair of tweezers could be located within the home's first aid kit. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | On 04/02/26, LHSS operations director visited all LHSS CLAs where he removed all first aid kits with missing items and replaced them with kits which contained all required items. |
04/22/2026
| Implemented |
| 6400.151(c)(3) | Staff #1 was hired by the provider agency effective 10/14/2025. Staff #1's Initial Physical Examination, dated 10/02/2025, did not note whether the individual was free from communicable disease. The area of the form designated for this information was left blank. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | Staff #1's medical provider's office was contacted and it was determined that this portion of the physical exam documentation was accidentally not completed. LHSS received a revised copy on 04/16/26 which indicated that Staff #1 had been determined to be free of communicable disease during their 10/14/25 examination. |
04/22/2026
| Implemented |
| 6400.52(a)(1) | Per the 2025 Staff Training Record, Staff #2, who is a Direct Service Worker, completed only 17.2 Hours of training during the training year. Direct Service Workers are required to complete 24 hours of training per year. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | Staff #2 completed all training which had not been completed during the 2025 training year by 02/10/26. |
02/10/2026
| Implemented |
| 6400.52(c)(3) | Staff #2's 2025 Staff Training Record did not contain evidence that the staff completed training on the following topic during the training year: Individual Rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Staff #2 completed training on Individual Rights on 02/14/26. |
02/14/2026
| Implemented |