| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.104 | Fire Department Notification letter dated 11/5/2025 (confirmed typographical error and should be 11/5/2024), stated that there are two Individuals residing at this home. Individual #1 passed away on 7/18/2025. To date (8/12/2025), a new fire department notification letter has not been sent updating the number of individuals residing in the home. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| A fire letter was completed and sent out the day that this citation was noted. Review of all books was completed to ensure that all fire letters were done when any individual moved in or out of a home. |
09/09/2025
| Implemented |
| 6400.145(1) | The emergency medical plan for this home states that "staff person should take the Individual to the nearest hospital location," followed by a list of 3 different hospitals. This emergency medical plan is not person-specific for the Individuals residing in the home listing their preferred hospital and transportation method. | The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. | LCSS administrative staff have met with each individual and have updated the emergency plan for each person specific to that individuals preference in which hospital and what method of transportation they prefer. |
09/09/2025
| Implemented |
| 6400.151(c)(2) | Staff #5 received Tuberculin skin testing on 6/12/2023 and no testing since. There is no documentation from their healthcare provider stating that the repeat test is not indicated for the staff person at the 2-year follow up physical exam. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | All physical¿s that was completed, both staff and individual, has been sent to the completing physician to have this information documented correctly.
Individual and staff physical forms have been updated to include the last completed TB with results and date, and a question for the PCP to fill out asking if they feel it is medically necessary to have a repeat testing since the last. If the answer is no, the PCP will not be tested. If the PCP feels that it is necessary, the testing will be completed by the PCP and the results from that test will be indicated on the physical. |
09/09/2025
| Implemented |
| 6400.181(e)(7) | Individual # 2's assessment dated 02/05/25 does not include his ability to move away from heat sources. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | The assessment that was reviewed was updated and sent to all team members.
All assessments for LCSS individuals have been reviewed by the program specialist and any updated information, including the ability to move away from heat sources. |
09/09/2025
| Implemented |
| 6400.183(a)(3) | (REPEAT 09/03/24)- Individual # 2's plan was not implemented regarding a request to go to the hospital on 05/03/25 after refusing to take medications. There is no documentation that the behavior support plan; which addresses repeated hospitalization requests (under the target behavior of "Fabrication"); was followed. Nor is there documentation of behavior support plan interventions for "fabrication" by staff as per the report of the CEO. Additionally, the BSP dated 12/17/24 reads "daily caffeine restriction of 250 mg in place", however, on 03/05/24 it was ordered "avoid all caffeinated drinks and foods". The plan cannot be implemented as written. | The individual plan shall be developed by an interdisciplinary team, including the following: The individual's direct care staff persons. | New behavior support tracking for all target behaviors will be created by the behavior specialist and staff will be trained on this new document at the upcoming meetings that is scheduled for the week of 09/15/2025. This document will include that if any of the behaviors of concern occur an abc will be need completed at that time along with the new document. |
09/22/2025
| Implemented |
| 6400.183(a)(3) | Individual # 2's ISP meeting on 06/05/25 did not include a Direct Support Professional. | The individual plan shall be developed by an interdisciplinary team, including the following: The individual's direct care staff persons. | Since our licensing review, an ISP has been held for another individual, which also included a direct care staff. |
09/09/2025
| Implemented |
| 6400.195(c)(3) | Individual # 2 has a behavioral support plan signed on 12/17/24 which identifies 9 target behaviors. Specific outcomes for each targeted behavior are not identified. | The behavior support component of the individual plan shall include: The outcome desired. | Behavior Support and his assistant are reviewing all behavior plans to ensure that all plans have outcomes listed for all targeted behaviors and a target date for each outcome. |
09/22/2025
| Implemented |
| 6400.195(c)(4) | Individual # 2 has a behavioral support plan signed on 12/17/24 which identifies 9 target behaviors. There is no target date to achieve the outcomes for each of the 9 targeted behaviors. | The behavior support component of the individual plan shall include: A target date to achieve the outcome. | Behavior Support and his assistant are reviewing all behavior plans to ensure that all plans have outcomes listed for all targeted behaviors and a target date for each outcome. |
09/22/2025
| Implemented |