| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | The individual funds shall be used for the individual benefit. It was noted a the time of the inspection that individual receives food stamps and the grocery receipts reflect that on several occasions he had purchased necessity food rather than his preferred snack items. Some of the items purchased on the receipts were spareribs, chicken wings, yogurt, ground beef, lettuce, stuffing, such items shall be provided by the agency by way of room and board. | Individual funds and property shall be used for the individual's benefit. | Individual has been fully refunded of all his personal funds that was used to complete essentials food purchase. Moving forward all petty cash receipts will be filed in the Individual¿s financial book. |
08/05/2025
| Implemented |
| 6400.64(a) | Clean and sanitary conditions shall be maintained in the home. At the time of the inspection individual #1 bedroom floor had brown marks on the grey carpet. It was reported by staff that individual defecates on the floor and the marks on the floor were stains from this. In addition to the stains on the bedroom floor the closet also had heavier stains and a strong foul order from said behaviors. | Clean and sanitary conditions shall be maintained in the home. | Individual #1 bedroom was thoroughly and professionally cleaned immediately after licensing July 25, 2025. |
08/05/2025
| Implemented |
| 6400.67(b) | Floors, walls, ceilings and other surfaces shall be free from hazards. At the time of the inspection there were several incense found around individual #1 bedroom. There was a small votive candle holder in the closet with 2 incense and used matches that appeared were burned. Also, on individual bedroom dresser there was an old candle which held over 10 burned incenses. Also on the dresser was a plastic baggie of incense bombs that were not yet used. This individual has a history of fire setting, and the items found in his bedroom are very much a hazard due to his history. The staff were unaware these items were in the bedroom at the time of inspection and were unaware of when individual purchased these items. | Floors, walls, ceilings and other surfaces shall be free of hazards. | On July 31st, 2025, a team meeting was held for Individual # 1 with his entire support team. His ISP discrepancies with regards to candle and incense burning has been addressed by the entire team based on the Individual¿s needs and safety. |
08/05/2025
| Implemented |
| 6400.141(a) | The individual shall have a physical exam prior to admission and annually there after. Individual #1's date of admission was 6.24.24. The exam prior to the admission was dated 4.23.24. There was no documentation to reflect individual had an annual physical exam. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #1 annual physical has been completed July 24th, 2025. |
08/05/2025
| Implemented |
| 6400.211(b)(1) | The emergency record did not list the name, address and telephone number and relationship of a designated person to be contacted in the case of an emergency. | Emergency information for each individual shall include the following: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency.
| Agency has created a medical authorization and consent for emergency treatment form immediately after licensing. The form has been signed by the Individual and all pertinent information listed on it. |
08/05/2025
| Implemented |
| 6400.211(b)(3) | The emergency record did not list the name, address and telephone number of the person able to give consent for emergency medical treatment. | Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.
| Agency has created a medical authorization and consent for emergency treatment form immediately after licensing. The form has been signed by the Individual and all pertinent information listed on it. |
08/05/2025
| Implemented |
| 6400.214(b) | The individual records including the dental exam and dental hygiene plan or annual assessment was not in the home at the time of inspection. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| A copy of the individual¿s records including the dental exam and dental hygiene plan and annual assessment are now in his home. A copy of his medical and permanent record books has been placed in his home. |
08/05/2025
| Implemented |
| 6400.32(r)(5) | Staff who provide services to the individual shall have a key to unlock the bedroom door. At the time of the inspection, licensing rep requested that staff show her the key that would unlock the individual bedroom door. Staff were unable to locate said key. Staff contacted their coworker who was with the individual at the time and it was reported that individual #1 took both his key and the staff key with him. Staff report he purposely took both copies of the key due to the inspection today and did not want people in his bedroom however he did not close his bedroom door or lock it. | Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door. | All staff members working with Individual #1 have been provided with keys to the individual bedroom July 23, 2025. |
08/05/2025
| Implemented |
| 6400.182(c) | The individual plan shall be initially developed ad revised annually and revised when an individual's needs change based on a current assessment. The Individual Support Plan (ISP) for Individual #1 dated 6.24.25 (revised 7.21.25) reflects contradicting information which should be reassessed and updated to reflect the most accurate information. The current ISP reflects the individual does not have any unsupervised time in the home but can spend time in other rooms of the home with visual check ins every 60 minutes. In the behavioral plan section the plan reports that the individual is able to use a "tap out" procedure which allows him space from staff to de-escalate. The behavioral plan reports that he can use the "tap out" plan 2 times per shift as he has been approved for 3 nonconsecutive hours of alone time per day. This procedure allows staff to leave individual in the home alone while he calms down. It was reported that staff can sit in their car for this period and watch the exit door as individual is said to be an elopement risk. The concern here is that there are two main entrances to this apartment. If staff are on the back side, they would not see him elope from the front door and vice versus. The information regarding supervision in the ISP is contradicting and should be updated as needed. In addition to the supervision piece. In addition to the supervision the financial needs are also contradicting among the assessment and ISP. The annual assessment dated 8.24.24 reports that individual needs total assistance to perform the entire skill regarding his ability to pay for items with money and knowing what change to get back and with recognizing the value of money and understanding budgeting. However, the ISP reports he has a rep payee through advocacy alliance since Feb 2025 and he manages his personal spending independently. There appears to be a struggle with individual's financials as he obtains finaical gains on internet games to which funds are deposited into an account of his. In addition, he has applied for several credit cards and opened several bank accounts on his own. It is uncertain how as he has no unsupervised time in the community and staff should be within eyesight at all times. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | On July 31st, 2025, a team meeting was held for Individual # 1 with his entire support team. His ISP discrepancies with regards to visual check in every 60 minutes has been addressed by the entire team based on the Individual¿s needs and safety. |
08/05/2025
| Implemented |
| 6400.210(b)(1) | The individual's personal funds or property may not be used as a payment for damages unless the individual consents to make restitution for the damages. An investigation identified LHSS was responsible for reimbursing iIndividual #1 $1,177.00 for the cost of an Apple Laptop. There were several outstanding balances of room and board that were deducted from the total amount to be reimbursed. Also included in the deductions from the overall balance owed to the individual was his damage to a 55 inch LCD TV purchased by LHSS in the amount of $211. There is no consent given for a deduction of the $211. The individual should not be held liable for the $211 cost of the tv that was damaged. | An individual's personal funds or property may not be used as payment for damages unless the individual consents to make restitution for the damages. The following consent provisions apply unless there is a court-ordered restitution: A separate written consent is required for each incidence of restitution. | Individual consent to an agreement of paying for all damages he may have caused. He initially signed the agreement December 4th, 2024, and signed a copy that was amended January 31st, 2025. The Individual willingly agreed to the terms and conditions of the agreement. It is also discussed and agreed during a team meeting that any changes to the agreement must be fully discussed and explained to the Individual to ensure he is in full agreement of the changes before pending his signature. |
10/13/2025
| Implemented |