| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | Water temperature measured above 120 degrees in the kitchen and the Individual 1's shower was measured at 130.6°F. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The Plumber was called and a 24hr remediation was effected. Furnace temperature was adjusted and water temp rechecked at 115 degrees F (see shared folder submission for evidence) |
09/10/2026
| Implemented |
| 6400.71 | The emergency contacts posted for emergencies listed hospitals that were closed. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| Updated and accurate Emergency contacts were posted in the houses and old ones taken down |
08/24/2026
| Implemented |
| 6400.72(a) | A window in Individual 1's bedroom was operable but did not have a screen. A window in an unoccupied bedroom was also missing a screen. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Window screen was fitted and broken one replaced. (see shared folder for fitted screens) |
09/09/2026
| Implemented |
| 6400.72(b) | The window in the unoccupied bedroom that had a screen had a whole in it. | Screens, windows and doors shall be in good repair. | A new screen has been fitted (see shared folder) |
09/09/2026
| Implemented |
| 6400.74 | The interior stairs lacked a nonskid surface. | Interior stairs and outside steps shall have a nonskid surface.
| Non-skid carpets placed on all basement and interior stairs (see shared folder) |
08/28/2026
| Implemented |
| 6400.77(b) | The residence's first aid kit was missing tape. | 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. | Tape replaced in first aid kit |
08/14/2026
| Implemented |
| 6400.80(b) | Debris filled the landing area and stairs at the basement door exit. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | Basement outside landing area cleared |
08/14/2026
| Implemented |
| 6400.110(e) | The interconnected fire alarms did not sound together when activated. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | smoke alarms replaced and re-tested to ensure all alarms in the three floors are interconnected (see shared folder for evidence) |
08/28/2026
| Implemented |
| 6400.113(a) | The fire drills provided contain incongruent information and are not a reliable measure of monthly compliance. Individual 1 moved to this new home on 04/23/2026 -- the fire drill recorded that date reports a 2:00am drill time, and reports that the fire extinguishers in the home were last inspected June 2026, after the date signed as completed. Fire drills were reported 03/05/2026 and 04/01/2026, listing Individual 1 as a participant - these fire drills occurred prior their move into the home 04/23/2026. | 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. Fire drills exist for 03/05/2026 and 04/01/2026 and include Individual 1 as the only resident, which conflicts with their move-in date. | Fire drills have been repeated. House supervisors have been retrained on the importance of accurate reporting and recording of drills. |
08/20/2026
| Implemented |
| 6400.141(a) | Individual 1's annual physical exams were dated 12/17/2025 & 10/07/2024, which exceeds the annual timeframe and grace period. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual 1 changed their PCP after their last physical. Unfortunately, we couldn't secure any earlier appointment for an annual review until dec 2025. |
09/14/2026
| Implemented |
| 6400.142(a) | Individual 1 had a dental appointment completed 08/12/2026, which was more than one year since the last completed appointment documented on 08/07/2024. [REPEAT VIOLATION] | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Individual 1 had a dental appointment on 09/24/25, perhaps it was missed during the inspection. p(ls see shared folder) |
09/14/2026
| Implemented |
| 6400.144 | Individual 1 had prescribed medications not present in the home. Polyethylene Glycol Powder was not present in the residence for inspection. Loratadine 10 MG was not present in the residence for inspection. The Polyethylene Glycol Powder was refilled the day of inspection. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Polyethylene Glycol was refilled on day of the inspection and the Loratadine 10mg was discontinued by the PCP on 08/14/2026. Medication refill shall be checked one week to refill by the house supervisor and such will be brought to the notice pf the nurse. All refills are automatically set to refill by the PDC pharmacy but should it not arrive within 4 days prior to the end of the medication, the supervisor shall bring this to the attention of the nurse. Both house supervisors and agency nurse shall be held responsible. |
08/18/2026
| Implemented |
| 6400.151(a) | Staff 2 's two most recent physical exams were completed 06/25/2026 and 10/09/2023, which exceeds the biennial requirement. | 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. | We accept this as a management oversigth. An internal audit has been conducted of all staff and violations identified and currently being remediated by HR to make sure every staff is in compliant |
09/14/2026
| Implemented |
| 6400.181(a) | Individual 1's annual assessments were dated 02/17/2026 & 01/31/2025, which exceeds the annual timeframe. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | The lapse was as a result of a one month compassionate leave granted to the previous PS to visit with their ailing father. following the post inspection management review meeting. It has been agreed upon that all reviews if not completed before granting leave must be passed on to the program director for completion or further instructions to avoid time lapses. |
08/18/2026
| Implemented |
| 6400.181(e)(10) | Individual 1's annual assessment did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | The lifetime medical was in her older folder as we had purged the folders due to too many overlaps in documentations. (pls refer to shared folder for an updated LTM) |
09/10/2026
| Implemented |
| 6400.46(a) | Fire safety training for Staff Member 2 was completed 07/31/2026 and 08/06/2024, which exceeds the annual requirement. | Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Fire training was done inhouse on 02/05/25 along the fire safety application submitted to the fire department . |
09/14/2026
| Implemented |
| 6400.52(a)(1) | Staff Member 2 had 16.5 hours of credited training in the last completed training year. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | Staff is currently working on her 2026 training to ensure 24 required hours are achieved within the training cycle. |
09/14/2026
| Implemented |
| 6400.163(b) | Sertraline Tab 50MG was initialed on the medication administration record as being given, but the blister pack was missing doses for both August 14 and 15. | A prescription medication may not be removed from its original labeled container in advance of the scheduled administration, except for the purpose of packaging the medication for the individual to take with the individual to a community activity for administration the same day the medication is removed from its original container. | Agency nurse organized a retraining session for all staff especially those in 734 to review how blister packets need to be dispensed and staff are now required to sign on every pocket popped. This will be reviewed in a month for compliance.(see training evidence in shared folder) |
08/19/2026
| Implemented |